DERMAL FILLERS FORM

Please fill out and submit the Consultation Form below which enables us to treat you.

* - Required Field.

First Name*
Last Name*
Are you 18 or over?*
Date of Birth*
Phone*
Email Address*
Address*
Postcode*
CONSENT FOR DERMAL FILLERS (HA) & PROFHILO

I am aware that the treatment is carried out by injection for the improvement of lines wrinkles and folds of the skin, for lip augmentation, skin and facial contouring.
I consent to receiving the treatment.
I understand the importance of withholding any medical conditions may be detrimental to my health and the outcome of the procedure.
I confirm that it is my responsibility to ask sufficient information about the treatment and product.
Results: An average of 6-18 months but may vary depending on the condition of the skin, area treated, amount of product injected and lifestyle factors such as sun exposure, smoking, metabolic rate.
I understand that the effect will gradually wear off and additional treatments may be necessary to maintain the desired effect: *
POSSIBLE SIDE EFFECTS & COMPLICATIONS

Due to the use of a needle there is likely to be some bleeding, bruising, redness, swelling, stinging, itching and or discomfort at the injection site. Injections into the lip area could trigger cold sores (Herpes simplex).
Risks: allergic reaction, infection, necrosis, vessel occlusion, granulomas, abscess formation, hypersensitive reaction, lumps, migration of product and asymmetry.
Post treatment: avoid extreme facial expressions, alcohol consumption, smoking and applying makeup for 24 hours. Avoid extreme sun exposure, UV light, freezing temperatures and saunas for 2 weeks. Avoid manipulation of the treated area.
I understand that I must adhere to the aftercare advice: *
PRECAUTIONS & CONTRAINDICATIONS

Allergic reaction, filler is not recommended for those with a history of severe allergies or a history of anaphylaxis. The risk of bruising or bleeding may be increased by medications with anticoagulant effects, such as Aspirin and non-steroidal anti-inflammatories. High doses of Vitamin E and some supplements: *
ACKNOWLEDGMENT

I understand and acknowledge that payments for the above procedure are non-refundable and due at the time of service. 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 the need for topical anaesthetic may be necessary to reduce the discomfort of the procedure and consent to the application.
I certify that I have read and fully understand the content of this consent form for the procedure and that the disclosures referred to herein were made to me. I am not pregnant and I am not breastfeeding.
I understand and consent to photos for before and after comparisons.
I agree to follow all post treatment instructions carefully and understand that these guidelines are crucial for healing, prevention of side effects and complications. I have been informed of the risks and benefits of this treatment and wish to proceed with the treatment.
I hereby give consent to carry out the treatment of my choice.
I hereby release the practitioner, the person injecting and the facility from liability associated with this procedure and all future procedures.
I hereby authorise Dolly Patel to administer such treatment to me and agree to hold her free from any claims, suits or damages for any injury or complications resulting from this treatment.
I confirm that I accept all liability: *
Sign Your Name*
Date*