Your Med
UNIVERSAL CONSENT FOR PROCEDURE
I hereby consent to the performance of the procedure:
(precise name of procedure)
I have been thoroughly informed about:
◦ contraindications for the procedure,
◦ the technique and method of conducting the procedure,
◦ the origin and method of action of the products that will be used during the procedure,
◦ the effects achievable in my case,
◦ all possible outcomes and complications of the procedure,
◦ post-procedure care,
◦ the duration of the achieved result,
◦ the interval after which a repeat procedure may/should be performed:
(precise name of procedure)
◦ the minimum number of procedures required to maintain the achieved effect.
I have received detailed information on how to prepare for the procedure at home, including recommended products to use __ days before the procedure. The doctor also informed me that omitting this preparation may affect the outcome.
I was informed that the results of the procedure depend on:
(list patient characteristics such as age, skin condition, and other factors that may affect the outcome).
The doctor also informed me that results may vary between patients.
I have also received comprehensive information about any consequences and complications that could arise from not following the doctor’s instructions in the period:
I have been informed that after the procedure:
◦ inflammatory reactions such as redness, swelling, edema, or erythema may occur, which could be accompanied by itching or pain upon touch. These reactions may last up to approximately seven days,
◦ hardness or lumps may appear at the injection site,
◦ isolated cases of skin necrosis in the glabellar region after product application, abscesses, granulomas, and hypersensitivity have been reported.
Before the procedure, I provided full and truthful answers to the doctor’s questions during the medical interview regarding:
◦ my health condition,
◦ presence/absence of pregnancy,
◦ current medications,
◦ previous procedures.
The information provided by the doctor was thorough, comprehensive, and fully clear and understandable to me. I acknowledge that any negative outcomes or complications, as informed by the doctor prior to the procedure, do not entitle me to compensation claims. I also understand that discrepancies between the actual result, as defined by the doctor before the procedure, and my expectations cannot form the basis for any claims. I had the opportunity to ask questions about the proposed procedure during my discussion with the doctor.
I hereby declare that I have read the above text and give my informed consent to undergo the procedure.
Patient’s Name and Surname
Address
Date of Birth
Contact Number
Allergies
Chronic Illnesses
Other
Language Clause
This document has been prepared in both Polish and English versions. In the event of any discrepancies between the two versions, the Polish version shall be considered binding.