PROFHILO CONSENT FORM

INSTRUCTIONS

This is an informed consent document that has been prepared to help inform you concerning Profhilo injections and the risks involved. It is important that you read this information carefully and completely. Please read each page and sign the consent at the bottom prior to your treatment.

INTRODUCTION

Profhilo is a product containing hyaluronic acid and amino acids. It is used to smooth out wrinkles, hydrate the skin, and improve skin texture that has lost its volume and fulness due to ageing, sun exposure, illness etc. This particular combination of HA and amino acids helps to stimulate the extracellular matrix of the skin. Facial rejuvenation can be carried out with minimal complications. Treatment may require a course of 1-3 sessions, each 1 month apart and the results can often be seen 3 days after injection and last between 3-6 months.

RISKS OF PROFHILO INJECTIONS

Every procedure involves a certain amount of risk, and it is important that you understand the risks involved. An individual’s choice to undergo a procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience these complications, you should discuss each of them with your practitioner to make sure you understand the risks, potential complications, and consequences of Profhilo injections:

• Post treatment discomfort
• Bleeding
• Bruising/Swelling
• Numbness or itching
• Inflammation
• Infection
• Lumpiness
• Skin discolouration
• Localised necrosis if blood vessel occlusion occurs

CAUTIONS & CONTRAINDICATIONS (To be checked with patient prior to treatment)

• Known hypersensitivity to ingredients or any of its excipients e.g. Lidocaine
• Anticoagulant use (e.g. Warfarin/Aspirin)
• Pregnancy/Breastfeeding
• Infected skin area e.g. cold sores/cellulitis etc

PATIENT CONSENT

General information

• I confirm that I consent to receiving treatment using the products that my practitioner has recommended to me.
• I have been informed that the treatment is carried out by injection for the improvement of skin texture, lines, wrinkles, rehydration of the skin.
• I have been given sufficient information to enable me to understand the use of these products for the approved indications.
• I understand that though complications are uncommon, they do sometimes occur. It is possible that side effects not described may occur and indeed that a complication not previously reported may occur for the first time.
• I understand that if I suffer any adverse reactions that are not expected, or concern me, I must contact the clinic. An appointment will be made for me to be seen. The clinic cannot take responsibility for complications or results that have not been reported, assessed, documented and managed in a timely fashion.
• I have also received information regarding contraindications to the administration of products and potential side effects.
• Profhilo treatments give an aesthetic result for a limited time period. This effect may be variable depending on many factors, including condition of the skin, mechanical action in the treatment area, amount of product injected and technique for injection. Lifestyle factors also effect the duration of the product. Regular top-up treatments help to optimise the duration of the product.
• Post treatment: Following treatment, avoid sun exposure and saunas. Avoid manipulation of the treated area and make up, as instructed by your practitioner
• I understand that whilst I have been advised as to a probable result, this should not be interpreted as a guarantee.
• I confirm that I have been provided with verbal and written information about this treatment which includes aftercare and follow up advice.
• I agree to follow the aftercare advice and understand this reduces risk of adverse reactions, promotes healing and helps ensure optimum results

General information about Profhilo injections

• Injections of Profhilo are to smooth out wrinkles, hydrate the skin, improve skin texture, and stimulate collagen.
• Treatment is expected to last for a period of 3-6 months depending on the area treated. The successful outcome varies by degree and how long it lasts varies from one individual to another and cannot be guaranteed.
• The possible side effects of Profhilo include but are not limited to:
  • Risks: I understand there is a risk of redness, swelling, haematomas, bruising, local numbness, pain at the injection site, and allergic reaction. Resolution is typically spontaneous within a few days
  • Infection: there is a minimal risk of infection which in most cases are easily treatable but in rare cases a permanent scarring in the area can occur.
  • As with all injectable treatments, there is a minimal risk of vessel occlusion, granulomas, abscess formation and hypersensitive reaction.
• Persistence of any inflammatory reaction for more than one week or the development of any other side effects must be reported to the practitioner as soon as possible.
• Perfect symmetry is not always achievable.
• After-care instructions: you may use a cold pack to reduce swellings and/or redness; do not massage or manipulate the treated area; avoid wearing make up for 12 hours; avoid extreme temperatures (hot or cold) such as saunas, steam rooms, sunbeds or sun exposure, for a minimum of 7 days after treatment; apply SPF 30+ sunscreen; avoid strenuous activity for 24 hours; avoid alcohol for 24 hours after treatment.

Photography

• I understand that photographs will be taken throughout my treatment plan and will form part of my confidential treatment records.

Payment

• I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I further agree in the event of non-payment, to bear the cost of collection, and/or court cost and reasonable legal fees, should this be required. I understand that treatments are non-refundable and carried out at my own risk with informed consent.

Data Protection

• I understand information about me will be treated as confidential and access to it restricted in accordance with the Data Protection Act, unless specific permissions given.
• I understand that there may be circumstances in which my medical records will need to be shared with appropriate professional staff, such as in the case of an emergency or complication.

I acknowledge that I have read the Clinic Terms & Conditions, and the foregoing informed consent, understand it, accept these facts and agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent treatments with the above understood. I hereby release the aesthetics practitioner, the person injecting Profhilo and the facility from liability associated with this procedure.