Clinic template
Polynucleotide consent form template (UK)
Free polynucleotide consent form template for UK clinics. Fish allergy screening, itemised risks, batch recording prompts and signature blocks.
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Version 2026-06-11. Adapt it for your clinic before use. Read the full HTML document.
- Audience
- Qualified aesthetic practitioners
- Available now
- Full HTML and a copyable text version, plus PDF and Word downloads
- Scope
- UK practice. Check the requirements where you practise.
- Before use
- Adapt the wording and check it with your insurer.
For qualified practitioners: a template to adapt, not clinical advice.
Use your clinical judgement for every patient. Check the products you use, your protocols, manufacturer instructions, your prescriber's directions where relevant, and your insurer's requirements.
The template
Patient details
Full name: ___________________________
Date of birth: ___________________________
Phone: ___________________________
Email: ___________________________
Address: ___________________________
Treatment details
Product (brand and presentation): ___________________________
Batch number: ___________________________ Expiry: ___________________________
Area(s) to be treated: ___________________________
Session number and total sessions planned in this course: ___________________________
Date of treatment: ___________________________
About this treatment
Polynucleotides are injectable preparations of purified DNA fragments, commonly derived from salmon, used to improve skin quality, hydration, elasticity and texture. They do not add volume or alter the shape of facial features. Treatment is usually given as a course of two to three sessions spaced several weeks apart, and results develop gradually over the weeks following the course. No specific outcome can be guaranteed.
Contraindications and screening
Please confirm each of the following:
- I do not have an allergy to fish or fish-derived products (required for salmon-derived polynucleotides; tell your practitioner if you are unsure)
- I am not pregnant and not breastfeeding
- I do not have an active skin infection, cold sore, acne flare or broken skin in the treatment area
- I do not have a known allergy to any component of the product or to local anaesthetics used during treatment
- I do not have a bleeding disorder and have disclosed any blood-thinning medication or supplements
- I have disclosed any autoimmune condition, immunosuppressive treatment or significant medical history
- I have disclosed all previous aesthetic treatments in the area, including filler, and any complications
Risk acknowledgement
I understand and accept the following recognised risks of polynucleotide treatment:
- Injection-site reactions including redness, tenderness and warmth, usually settling within a few days
- Small raised bumps (blebs) at the injection points, usually settling within 24 to 48 hours
- Bruising, which can take a week or more to fade, particularly around the eyes
- Swelling of the treated area
- Infection at the injection sites
- Allergic reaction, including (for salmon-derived products) reaction in people with an undisclosed fish allergy
- Rare vascular events, where product affects a blood vessel; these are uncommon and your practitioner will explain the warning signs, which need urgent assessment
Aftercare commitment
- I agree to follow the written aftercare instructions, including avoiding makeup until the injection points have closed, avoiding alcohol, strenuous exercise and heat for 24 to 48 hours, avoiding facials and similar treatments over the area for around 2 weeks, and using high-factor sun protection daily.
Photography
- I consent to clinical photographs being taken before and after treatment for my confidential patient record.
- I additionally consent to my photographs being used for marketing purposes (optional).
Outcome
- I understand that results develop gradually over a course of treatment, vary between individuals, and cannot be guaranteed, and that a single session is an incomplete treatment.
Patient declaration
I confirm that I have read and understood the information above, that I have had the opportunity to ask questions and that they have been answered to my satisfaction. The information I have given is true and complete. I consent to polynucleotide treatment as described.
Patient signature: ___________________________
Print name: ___________________________
Date: ___________________________
Practitioner declaration
I confirm that I have explained this procedure to the patient, including its intended benefits and material risks, and any available alternative treatments, and that the patient has had the opportunity to ask questions.
Practitioner signature: ___________________________
Print name and qualification: ___________________________
Date: ___________________________
This template is for UK aesthetics practitioners offering polynucleotide treatments. Polynucleotides are newer to most clinic menus than toxin or filler, which means many clinics are adapting a generic injectable consent form that misses the points specific to this category: fish allergy screening for salmon-derived products, the course-based protocol, and the expectation-setting around gradual, regenerative results. A defensible consent form is informed, specific to the product and areas treated, signed by patient and practitioner, versioned and retrievable on request.
Why each section exists
The fish allergy question is the section that earns this form its place. Most polynucleotide products on the UK market are derived from salmon or trout DNA, and a known fish allergy is a genuine exclusion for those products. A signed answer protects the patient first and the practitioner second. If the product you use is not fish-derived, adapt the wording, and check the manufacturer’s guidance for the specific product you use.
The treatment information paragraph does the expectation-setting work. Polynucleotide patients who expect a filler-style immediate change are the most likely to be dissatisfied, so the form states in writing that results develop gradually over a course and cannot be guaranteed. The product and batch fields matter because most polynucleotide presentations are not prescription-only medicines, which can tempt clinics into lighter documentation; the record-keeping standard does not relax, and batch-level recording is what makes a recall manageable.
England’s planned licensing scheme for non-surgical cosmetic procedures signals that written consent and complete treatment records will become baseline requirements across the sector. Insurers already expect itemised risk disclosure and evidence of screening; this template gives you both.
Using it in practice
Copy the template onto your own letterhead, name the product you actually use, and date the version so every signature can be matched to its exact wording. Complete the batch and expiry fields at the time of treatment, not afterwards, and record the session number so each visit in a course is individually documented. Treat the fish allergy question as a conversation, not a checkbox: ask it out loud and record the answer. For the clinical background to use in consultation, see our polynucleotides guide.
AesthetiClinic takes the admin out of this entirely: the consent form goes e-signed to the patient’s phone before the appointment, wording changes are versioned automatically, and the signed document files itself on the patient record. All the free documents live in the template library.
This template is provided as a starting point for UK aesthetics practice. It is not legal or medical advice. Review the wording with your insurer and, where relevant, your prescriber before use.
Before you use it
Adapt it for your clinic.
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Use your own details.
Name your clinic and the products and services you actually provide. Replace every placeholder before use.
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Review the wording.
Check the final form against your protocols, your prescriber's directions where relevant, and your insurer's requirements.
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Keep the version.
Date the final document and keep the exact wording used. Review it when your services, products or terms change.
Send forms to the patient's phone, capture an e-signature and keep the signed record.
See consent forms softwareCopy this template for your clinic.
Copy the full text into your own document and adapt it. Check the final wording with your insurer.
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Sources and corrections
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