Polynucleotides Consent Form

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


    • I have completed the polynucleotide treatment consultation and consent form honestly and to the best of my knowledge.
    • I understand what polynucleotide injections are and how they work, I also understand the expected outcomes of my treatment. I understand the contraindications and considerations. I understand post treatment care is my responsibility.
    • I understand that results can vary significantly between individuals due to differences in skin type, 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 polynucleotides are derived from salmon or trout and that individuals with allergies to fish or fish-derived products must not undergo this treatment. 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 polynucleotide injections are not permanent, as natural degradation will occur over time.
    • I understand that temporary side effects are common and may include redness, swelling, tenderness, bruising, itching, or mild discomfort at the injection sites. Small lumps or nodules can occur but usually resolve on their own. 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 polynucleotide treatment 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.