HYALURONIDASE 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*
When did you last have any treatments?*
Are you allergic to anything or any medication?
Are you breastfeeding, pregnant or undergoing IVF?
Are you currently receiving treatment or do you have any medical problems/autoimmune conditions/skin conditions?
Please list any medications you are on:
ACKNOWLEDGMENT

Please do not sign this document or proceed with your treatment until you are fully satisfied with the information given to you above.

It is your right to decline treatment and question your technician further if you do not understand anything discussed on this form.

By signing this document you are agreeing to have read and fully understood this information and therefore indemnify and hold harmless the treating clinician from any liability, cost, damages and expenses arising from treatment.

I understand that once treatment has begun I will be liable to pay the full cost of the treatment and that refunds are not available under any circumstances.

1.Hyaluronic acid can be degraded by a family of enzymes called hyaluronidases. As with any treatment it comes with risks. It is your responsibility to familiarise yourself with these risks in order for you to make an informed decision. Although good results are expected, the behaviour of Hyaluronidase is unpredictable and therefore it is difficult to proceed with accuracy each time and every time. In some circumstances hyaluronidase can break down areas of natural Hyaluronic acid, as well as areas of Hyaluronic acid added through injection that you do not want removed. In the event of a poor response from the enzyme, the face may appear uneven as some areas may be greater affected by the enzyme than others. It is because of this that there is no guarantee on the results that can be obtained through treatment. As with any treatment, dissatisfaction remains a real risk.

2.If an adverse effect is not purely as a result of a hyaluronic acid based treatment there is no guarantee that any form of resolution will be reached by using hyaluronidase. It is possible that these lumps, nodules, and other adverse effects are as a result of other factors including but not limited to; fibrous tissue, water retention, infection and cysts, instead of the product itself.

3.The most commonly associated risk with hyaluronidase is allergy. Although rare and most likely to be mild, anaphylaxis remains a real risk and can be life threatening. For this reason it is advised to have a patch test 30 minutes prior to treatment. A patch test should determine if an individual has an allergy to hyaluronidase but is inconclusive regarding whether a reaction to the treatment will occur in the future.

4. Other adverse reactions include but are not limited to pain, itching, bruising, swelling, inflammation, infection, numbness and scaring. Although unlikely, these may leave permanent damage. By signing this document I agree to the above and accept the below information; I consent to the use of anaesthesia if required.

I understand that photos will be taken and stored for 10 years and that these photos will not be used without my consent.

I understand that If I have not accepted a patch test then I have wavered my option to do so.

I understand that this treatment is not always necessary and for the most part is for purely cosmetic reasons.

I understand that hyaluronidase is charged per vials used and it is the responsibility of the patient to cover additional medical costs should complications occur.

I understand that under no circumstances do we offer full or partial refunds.

I understand that If I publish any negative results of my procedures on the internet via social media or other it will result in court proceedings.*
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Date*