EXOSOMES SKIN CONSENT FORM

Exosomes Skin 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 skin 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 illnessPsoriasisDermatitis or eczemaOpen wounds, lesions, or infections on the skinBacterial or fungal skin infectionsKeloid or hypertrophic scarsVitiligoSkin cancer or suspicious molesEpilepsyPregnant or breastfeedingAdverse reaction to anaesthetics or history of anaphylactic shockRecent sunburn on the treatment area 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 treatment area? Laser or IPL on the face/skinMicroneedlingBotox or fillerPRP or PRF treatmentsExosome therapyPolynucleotide injectionsChemical peel or resurfacing treatmentHair removal (waxing, threading, depilatory creams)Steroid injectionsSurgery or trauma to the area Have you used any of the following on your skin in the last week? Strong exfoliating or peeling productsTopical retinoids (Retinol, Tretinoin, Adapalene)Resurfacing agents (Alpha-Hydroxy-Acids, Salicylic Acid)Antimicrobial agents (Benzoyl Peroxide, Isopropyl Alcohol)Bleaching or depigmenting agents (Hydroquinone, Kligman’s formula)

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 skin rejuvenation. 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 am not currently pregnant or breastfeeding, and I understand that this treatment is not suitable during pregnancy or breastfeeding.

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

I understand that results can vary significantly between individuals due to differences in skin 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 skin ageing 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 treated area. Rare but possible risks include infection, allergic reaction, prolonged swelling, granuloma formation, or unsatisfactory results which may appear days or weeks later.

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 acknowledge that the clinic is not liable for complications that arise from failure to follow aftercare instructions.

I understand that several treatment sessions may be recommended to achieve the best results, and that one session alone may not produce noticeable or lasting effects.

I confirm that I have not had injectable fillers, Botox, PRP/PRF, polynucleotides, or other regenerative or injectable treatments in the treated area within the timeframe advised by my practitioner, unless disclosed.

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 skin rejuvenation 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: