EXOSOMES HAIR CONSENT FORM

Exosomes Hair Consent Form

A copy of this completed consent form along with post treatment advice will be emailed to the email address you provide below.

What are your primary concerns with your hair that you wish to be treated with exosome therapy? Do you have any known allergies? (E.g. latex, metals, shellfish, nuts, penicillin, anaesthetic agents, P-aminobenzoic (PABA), sulphonamide allergies, fish or fish-derived products including salmon or trout). Do you currently have or have you ever had any of the following? Allergy to fish, seafood or fish-derived products (e.g. salmon or trout)Autoimmune disorders (e.g. lupus, rheumatoid arthritis, alopecia areata)Cancer (current or history)Diabetes (Type I or II)Cardiac conditions or arrhythmiaHepatic (liver) diseaseHaemophilia or bleeding disorderAtopy or other known allergiesOther chronic illnessPsoriasis of the scalpDermatitis or eczema of the scalpOpen wounds, lesions, or infections on the scalpBacterial or fungal scalp infectionsKeloid or hypertrophic scarsVitiligoSkin cancer or suspicious molesEpilepsyPregnant or breastfeedingAdverse reaction to anaesthetics or history of anaphylactic shockRecent sunburn on the scalp Any other medical conditions not listed above? Are you currently taking (or have taken in the last 3 months) any of the following? Blood thinners (e.g. Aspirin, Warfarin)Isotretinoin (Roaccutane / Accutane / Isotane)Steroids or immunosuppressantsContraceptive pillFish oils, plant oils, Omega 3sGinseng, Gingko Biloba, St John’s WortPhoto-sensitising medications (e.g. antibiotics, antidepressants, anti-anxiety meds) Have you had any of the following procedures in the last 2 weeks on the scalp? Hair removal on the scalp (waxing, plucking, depilatory creams)Laser or IPL on the scalpMicroneedling on the scalpBotox or filler near the scalp/hairlinePRP or PRF treatmentsExosome therapyPolynucleotide injectionsHair transplant surgerySteroid injections into the scalpChemical peel or resurfacing treatment on the scalp Have you used any of the following on your scalp in the last week? Topical Minoxidil (Regaine)Steroid creams or lotionsAntibiotic creams or lotionsStrong exfoliating or peeling scalp productsTopical retinoids (Retinol, Tretinoin, Adapalene)

I have completed the exosome with microneedling therapy consultation and consent form honestly and to the best of my knowledge.

I understand that this treatment involves both exosome therapy and microneedling. I acknowledge that microneedling carries its own risks, including temporary redness, pinpoint bleeding, swelling, tenderness, mild discomfort, bruising, scabbing, and in rare cases, infection, scarring, or pigmentation changes.

I understand what exosome therapy is and how it works for hair restoration. I also understand the expected outcomes of my treatment. I understand the contraindications and considerations. I understand post treatment care is my responsibility.

I confirm that I have not used resurfacing agents, strong topical retinoids, or undergone chemical peels/laser treatments on my scalp in the past 7 days.

I understand that results can vary significantly between individuals due to differences in scalp condition, genetics, age, lifestyle and natural healing responses. I accept that results may not fully meet my personal expectations and no outcome is guaranteed.

I understand that some exosome products are biologically derived and may be unsuitable for those with fish, salmon or trout allergies. I confirm that I have disclosed any such allergies.

I understand that while good results are expected, complications are possible, and their nature cannot be fully anticipated. Therefore, no guarantees, expressed or implied, have been made regarding the success or outcome of the treatment. I am aware that the effects of exosome therapy are not permanent, as natural degradation and continued hair loss may occur over time.

I understand that temporary side effects are common and may include redness, swelling, tenderness, mild discomfort, bruising, itching or sensitivity of the scalp. Rare but possible risks include infection, allergic reaction, prolonged swelling, or unsatisfactory results.

I agree to follow all pre-treatment and post-treatment advice provided by my practitioner. I understand that failure to follow aftercare guidance may affect my results and increase the risk of complications.

I accept that all treatment fees are final and non-refundable once treatment has been provided, regardless of the outcome or my personal satisfaction with the results.

I authorise Qaya Clinic to perform exosome therapy with microneedling for hair restoration using the most appropriate products and techniques as recommended by my practitioner.

I have had the opportunity to ask questions about the treatment, including its risks and alternatives. All my questions have been answered to my satisfaction.

Your Signature:

Practitioner Signature: