The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure named above. This material serves as a supplement to the discussion you have with your doctor/healthcare provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form.

Biorevitalization is the revitalization of skin in a biological way to rejuvenate, hydrate dry, tired and sun-damaged skin with an immediate effect with results lasting up to 2-3 years.

As with any procedure there are potential risks and complications associated with Skin Boosters Injections. You must be aware of the following possible risks before proceeding. You must fully discuss any questions with your practitioner.

Common complications:

These include pain, bleeding and bruising at the time of injection. After injection, the area may feel tender but should not be actively painful. If you experience significant pain then you must contact your practitioner as soon as possible for review. Bruising is dependent on several factors, most of the time bruising is mild but occasionally can be more significant. Bruising can take up to 2 weeks to fully resolve but should be much improved after 1 week. More uncommonly severe bruising can lead to haematoma formation, a collection of clotted blood. In this case the swollen collection of blood will need at least 2 weeks to resolve naturally and your practitioner will give you the appropriate after care advice. Your skin may appear red and swollen after the injection, this is usually mild and should improve after a couple of days, but it can last up to 14 days in some cases.

Uncommon complications include:

Skin infection (cellulitis) which presents as hot, red, shiny skin and you may also be generally unwell. In the case of suspected infection, you should contact your practitioner but also seek medical assessment as soon as possible as you will likely need antibiotics. Occasionally infection can form a swollen collection called an abscess. In this case you again must seek urgent medical attention. If you suffer from cold sores (a herpes virus infection of the lip) these can sometimes be reactivated following injections. Occasionally people can develop an unwanted inflammatory reaction and this can lead to nodule formation called granuloma. These often present as a delayed complication several months after the treatment. Several treatment options are available for granuloma formation and you may require medical assessment. Sometimes people can faint or feel faint with injections, you must tell your practitioner as soon as possible if you feel unwell during the treatment.

Rare complications include:

Allergic reaction including anaphylactic reaction which would require emergency medical assistance and transfer to hospital. Rarely, it can be injected into an artery blocking the flow of blood to the tissue being treated. This is known as vascular occlusion, if untreated it is serious because it can lead to death of tissue (necrosis) which may require reconstructive surgery to correct. In the rare event of vascular occlusion, it would be treated with emergency injections of a dissolving drug called Hyaluronidase. This is an enzyme that removes the hyaluronic acid occluding the blood vessel and can usually fully reverse the vascular occlusion leading to no long-term harmful effects. Your practitioner will be trained in how to use Hyaluronidase in an emergency, however if treatment with Hyaluronidase is not successful then you would require urgent medical assessment or assessment by a doctor who is a specialist in aesthetic medicine.

Alternatives to the procedures and options that I have volunteered for have been fully explained to me.

I understand that this is an "elective” procedure and that payment is my responsibility and is expected at the time of treatment.

I understand that I have the right to discontinue treatment at any time.

I authorize the taking of clinical photographs and videos and their use for scientific and marketing purposes both in publications and presentations. I understand that photographs and video may be taken of me for educational and marketing purposes. I waive my rights to any royalties, fees and to inspect the finished production as well as advertising materials in conjunction with these photographs.

I understand that several appointments may be necessary to produce optimal results and I will be notified, in advance of each session of treatment, about the location where the next treatment session is going to take place and the identity of who is going to be involved in my care at each stage. I also understand that I will be kept informed of progress and that I can change my mind at any point.

I have been advised of the relevant information associated with this treatment and I confirm that I fully understand this advice. This includes advice about:

- the aims/motivations for having the procedure and the desired outcome
- the risks inherent in the procedure
- the risks inherent in refusing the procedure
- the risks specific to me
- the expected benefits of the treatment
- the potential disadvantages of the treatment
- alternative procedures and their pros and cons - including the option of no treatment at all
- any uncertainties about and the likelihood of success of the procedure
- any follow-up treatment that may be required

I am the treating Aesthetic Nurse.  I discussed the above risks, benefits, and alternatives with the patient. The patient had an opportunity to have all questions answered and was offered a copy of this informed consent.  The patient has been told to contact my office should they have any questions or concerns after this treatment procedure.

• I have been asked what information I want and would need in order to make an informed decision. I have been given the opportunity to discuss my desired outcome fully in order for me to make an informed decision.

I certify that I have read the above consent and that I fully understand it. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction. No new information has become available that affects my decision to have the treatment or my decision to consent. I hereby consent to this procedure. This constitutes the full disclosure and supersedes any previous verbal or written disclosures.