POLYNUCLEOTIDE INJECTION CONSULTATION & CONSENT FORM

TREATMENT OVERVIEW

Polynucleotide treatments at QT Beauty & Aesthetics use bio-stimulatory DNA fragments to naturally regenerate and rejuvenate skin. These treatments aim to:

  • Enhance collagen and elastin production
  • Deeply hydrate and improve skin texture
  • Reduce fine lines, wrinkles, dark circles, scars, and stretch marks

Treatable areas include face, neck, décolleté, hands, and delicate zones like tear troughs or intimate areas. Generally administered in a series of 3–4 sessions spaced 3–4 weeks apart, with maintenance every 6–12 months. Multiple techniques are used: micro-needle, cannula, or mesotherapy depending on treatment area.

MEDICAL HISTORY

Please tick all conditions that apply:

  • Pregnancy or breastfeeding
  • Active infection (bacterial, viral) or cold sores
  • Autoimmune or collagen vascular disease
  • Cancer or current oncological treatment
  • Diabetes or impaired wound healing
  • Fish allergy (polynucleotides often derived from salmon DNA)
  • Blood clotting disorder or anticoagulants
  • Allergy to topical anesthetic
  • Recent cosmetic injectables (< 4 weeks)
  • Cold sensitivity (for cryo-technique)
  • None of the above

Additional details (meds, allergies, conditions):

RISKS & SIDE EFFECTS

Please check each to confirm your understanding:

  • I understand polynucleotide treatment involves injections to stimulate cellular regeneration.
  • I may experience redness, swelling, bruising, or tenderness at injection sites.
  • Temporary small bumps are common and usually resolve within hours.
  • Rare risks include infection, allergic reaction, hyperpigmentation, or scarring.
  • Effects take time — weeks to months — with full results after multiple sessions.

POST-TREATMENT AFTERCARE

Please confirm you understand the following:

  • I will avoid touching/pressing treated areas for 12 hours.
  • I will avoid sun exposure, saunas, intense exercise, and heat for 48 hours.
  • I will apply SPF 30+ daily and use only gentle cleansers for 7 days.
  • I will keep well hydrated (≥2L water/day) for 3 days post-treatment.
  • I will contact QT Beauty immediately if I notice excessive redness, lumps, or tenderness.

PHOTO/VIDEO CONSENT (OPTIONAL)

  • I consent to before & after photos for my medical record.
  • I consent to use of these photos for marketing or social media.
  • I do not consent to any photography.

CLIENT DECLARATION & CONSENT

Please confirm the following:

  • I confirm all medical information provided is accurate.
  • I have been informed of the procedure, risks, benefits, and alternatives.
  • I understand results vary and require multiple sessions.
  • I release QT Beauty & Aesthetics from liability for undisclosed medical conditions.
  • I consent to undergo polynucleotide injection treatment.