Dermal Fillers Consent Form Dermal Fillers Consent Form Dermal filler is a sterile gel consisting of non-animal, stabilised hyaluronic acid and a local anaesthetic called lidocaine. Hyaluronic acid is a sugar chain molecule, naturally occurring in the skin and throughout the body. The sterile gel is injected into the skin to correct facial lines, wrinkles and folds, for lip enhancement, for shaping facial contours including chin, cheeks, jawline and the nose and for skin rejuvenation. Common Side Effects Associated with the Injection Pain or stinging sensation when the injection is performed. Localized swelling, redness and or tenderness Bleeding at the sites of injection Bruising. Rarely, bruising may be severe and may persist for several weeks. Numbness or itching of the area following injection. Common side effects are expected to resolve spontaneously, within the first few days of treatment. Whilst not expected, it is possible that reactions described may persist for longer than expected and may inhibit your confidence to attend work or social events. You are advised to schedule treatment with this in mind, allowing time for common reactions such as bruising and swelling, to settle. Uncommon Side Effects Infection Inflammation Skin discoloration Infection or skin discoloration may occur within a few days, or weeks to months following treatment. Allergic or sensitivity reaction. Symptoms include; itching, rash, red itchy welts, wheezing, asthma symptoms, dizziness or feeling faint. Abscess formation Prolonged swelling which may occur early or present after several weeks Persistent lumps, nodules or papules Acne like formations A Foreign body reaction known as ‘granuloma’ presenting as lumps or nodules The blood supply to the skin may be interrupted by swelling or inadvertent injection into a vessel, causing pain, skin damage and possible scarring. Though extremely rare, transient visual disturbance or permanent blindness has been reported following injectable cosmetic treatment. Perfect symmetry is not always achievable. Correction is expected to last for a period of 9-12 months depending on the area and dermal filler used. The successful outcome varies by degree and how long it lasts varies from one individual to another and cannot be guaranteed. Consent(Required) Dermal filler is a sterile gel consisting of non-animal, stabilised hyaluronic acid and a local anaesthetic called lidocaine. Hyaluronic acid is a sugar chain molecule, naturally occurring in the skin and throughout the body. The sterile gel is injected into the skin to correct facial lines, wrinkles and folds, for lip enhancement, for shaping facial contours including chin, cheeks, jawline and the nose and for skin rejuvenation. Common Side Effects Associated with the Injection Pain or stinging sensation when the injection is performed. Localized swelling, redness and or tenderness Bleeding at the sites of injection Bruising. Rarely, bruising may be severe and may persist for several weeks. Numbness or itching of the area following injection. Common side effects are expected to resolve spontaneously, within the first few days of treatment. Whilst not expected, it is possible that reactions described may persist for longer than expected and may inhibit your confidence to attend work or social events. You are advised to schedule treatment with this in mind, allowing time for common reactions such as bruising and swelling, to settle. Uncommon Side Effects Infection Inflammation Skin discoloration Infection or skin discoloration may occur within a few days, or weeks to months following treatment. Allergic or sensitivity reaction. Symptoms include; itching, rash, red itchy welts, wheezing, asthma symptoms, dizziness or feeling faint. Abscess formation Prolonged swelling which may occur early or present after several weeks Persistent lumps, nodules or papules Acne like formations A Foreign body reaction known as ‘granuloma’ presenting as lumps or nodules The blood supply to the skin may be interrupted by swelling or inadvertent injection into a vessel, causing pain, skin damage and possible scarring. Though extremely rare, transient visual disturbance or permanent blindness has been reported following injectable cosmetic treatment. Perfect symmetry is not always achievable. Correction is expected to last for a period of 9-12 months depending on the area and dermal filler used. The successful outcome varies by degree and how long it lasts varies from one individual to another and cannot be guaranteed. Untitled(Required) I understand that whilst I have been advised as to a probable result, this should not be interpreted as a guarantee. Untitled(Required) 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. Untitled(Required) I understand 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. Untitled(Required) I understand that whilst results desired and expected have been discussed, outcomes vary between individuals and cannot be guaranteed. Untitled(Required) I confirm that the medical health history form has been completed truthfully and I am fully aware that withholding medical information, including history of previous treatment, may be detrimental to the safe and optimal outcome of any treatment administered. If there are any changes in my medical history, I must inform the practitioner. Untitled(Required) I confirm that I have been provided with verbal and written information about this treatment which includes aftercare and follow up advice. Untitled(Required) I agree to follow the aftercare advice and understand this reduces risk of adverse reactions and helps ensure optimum results. Untitled(Required) 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. Untitled(Required) I consent to my medical records being shared with appropriate professional staff Untitled(Required) I understand photographs are taken as part of my medical record. Consent(Required) A copy of this form is avaliable to you, please ask. Your consent and authorization to receive the treatment are totally voluntary. The nature of this procedure, the alternative methods possible as well as the complications were all explained to you. No guarantee of results has been promised to you. I accept the clinic terms and conditions. I am satisfied treatment with dermal fillers has been explained comprehensively and that the possible risks and side effects associated with the treatment have been fully discussed and understood. I have taken sufficient time to process and consider the information provided and any questions I had have been answered to my satisfaction, before making a decision to proceed with the agreed treatment plan. A copy of this form is avaliable to you, please ask. Your consent and authorization to receive the treatment are totally voluntary. The nature of this procedure, the alternative methods possible as well as the complications were all explained to you. No guarantee of results has been promised to you. I accept the clinic terms and conditions. I am satisfied treatment with dermal fillers has been explained comprehensively and that the possible risks and side effects associated with the treatment have been fully discussed and understood. I have taken sufficient time to process and consider the information provided and any questions I had have been answered to my satisfaction, before making a decision to proceed with the agreed treatment plan. Name First Last Signature Δ
