Consent Form – Medical Injectable Therapies

Strictly Private and Confidential

1. Treatment Summary

I consent to undergo injectable medical treatments at Priory Medical under the care of a registered physician. These include:

• Botulinum Toxin (neuromodulator therapy for regulation of muscle activity and related functional conditions)

• Hyaluronic Acid Gels (for medical restoration of facial structure, proportion, and support)

• Injectable Biostimulators (for stimulation of tissue repair, collagen production, and skin health)

All treatments are carried out strictly for medical purposes following clinical examination, assessment, and discussion of individual needs by the attending physician.

2. Risks and Expectations

I understand that all injectable medical therapies carry risks. Common side effects include redness, swelling, bruising, or tenderness at the injection site. Rare but serious risks include allergic reaction, infection, or vascular occlusion.

The outcome of treatment depends on my medical condition and response to therapy. The duration of effect varies between individuals and is temporary.

3. Medical History Disclosure

I confirm I am not pregnant or breastfeeding and have disclosed to the physician any relevant medical history, including but not limited to:

• Allergies (e.g., to lidocaine or product components)

• Neurological or autoimmune conditions

• Blood clotting disorders or use of anticoagulant therapy

• Recent dental work, viral infections, or facial procedures

• Medications that may affect immunity or healing

4. Aftercare Instructions

I agree to follow all aftercare advice provided by my physician, including:

• Avoid alcohol, strenuous exercise, or exposure to heat (e.g., sauna) for 24 hours

• Avoid pressure or massage of the treated area unless instructed

• Apply a cold compress if needed for swelling

• Contact the clinic immediately if I experience pain, changes in skin colour, or unexpected symptoms

5. Consent Declaration

I confirm that:

• I have been medically assessed and my suitability for treatment has been determined by a physician.

• The treatment, its risks, and expected outcomes have been explained to me.

• I have had the opportunity to ask questions and all were answered satisfactorily.

• I understand that results are not guaranteed, may vary, and may require follow-up treatment.

• I am giving consent voluntarily and am not under the influence of drugs, alcohol, or medication that could impair my judgement.

6. Photography Consent

Patient Confirmation