Rejuran Treatment Consent Form - The Aesthetic Chapter Singapore

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(IC) Identification Number / FIN

Todays Date

About Rejuran

Rejuran is a medical device composed of PN as main active ingredient that promotes favorable regeneration of cells from deep within the skin. It is a skin rejuvenating treatment made of Polynucleotides (PN) which are DNA fragments of specific size derived from wild salmon.

Treatment

Polynucleotide (PN) has been proven to be the most compatible to human skin without causing any adverse side effects. It stimulates your skin’s own regenerative capability: improves skin elasticity by recovering the biological condition of the dermis and epidermis, thereby improving the appearance of various skin concerns such as wrinkles; scars: large pores; redness and pigmentation

What you can expect from this treatmen

You will go through a general cleansing of your face and application of numbing cream for between 20 mins to 30 mins
Once the doctor is satisfied that the areas to be treated are properly numbed, the clinic assistant will remove the numbing cream, before the doctor proceed to manually inject your face with Rejuran. Typically, a Rejuran treatment will take about 10-15 mins
During the treatment, you may occasionally feel a pricking sensation, but otherwise the level of discomfort will be none or minimal.
Immediately after treatment, you will notice small raised bumps over majority o your face/treated area. Most of it will subside within a day. The tiny pricks from the needle will go away between 3-4 days.
I am aware to report any unusual side effects that might occur after the course of the treatment. (apart from those already mentioned in s/no 3d)
You will start feeling the effects of Rejuran approximately 4 weeks after the first treatment. For optimal result, it is recommended to do three treatments, one month apart.
I am aware that I can take up additional treatments to reach my desired outcome.
I have been briefed on post treatment care. (Eg. To refrain from smoking; sun- tanning alcohol; hot steam bath; sauna for 1 week etc)

Have done a Filler Procedure within 6 months on the same area

Are you currently being administered with NSAID Aggregation Inhibitor Anticoagulant; Immunosuppressant etc

Impaired Skin Sensation; Open and/ or Infected Wounds

Pregnancy or Lactation

Active Implanted Devices such as Pacemaker and Defibrillator

Recent Surgery or Scars on the Area to be Treated

I'm not hypersensitive to Polydeoxyribonucleotide

With my consent on submitting this electronic form :

I hereby authorize the doctor to perform Rejuran (HB/Healer/Scar/Eye) to me.
I also consent to being photographed and for digital images to being taken during the course of my treatments. The physician/technician will do their best to blur identifying details in the photographs in order to keep my identity discreet.
I certify that I have read all the above informed consent and fully understand it. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction, and thereby consent to the terms of the agreement.

ACKNOWLEDGMENT

BY MY SUBMISSION BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR THE USE OF REJURAN, AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION BY MY HEALTHCARE TEAM.

Patient Consent Form (Rejuran HB/ Healer/Scar/Eye)