Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Do you take regular exercise? *

Yes

No

Are you pregnant or breast feeding? *

Yes

No

Have you a history of severe allergy/anaphylaxis? *

Yes

No

Risks of injection: *

Trauma during the procedure is caused by needles and cannulas passing through tissue, and includes bleeding, bruising, haematoma (a larger collection of blood in the skin, outside of blood vessels), damage to underlying structures including veins, arteries, nerves, salivary glands, lymph nodes, bone, muscle and other soft tissue structures are possible. In rare cases this could cause continuous problems in appearance, sensation or function and may require medical intervention to treat or may be permanent. Most traumatic injuries heal completely on their own

Yes, I understand

Reactions: *

Allergic reaction including anaphylactic shock are possible, they occur at a rate of between 1/2000 and 1/100 depending on the data source. Anaphylactic shock has a mortality rate 0.3 to 5% depending on the study. An allergy test can often identify this risk prior to full exposure. Local reactions include oedema, erythema, pain and itching, urticaria and angioedema.

Yes, I understand

Side Effects: *

Hyaluronidase dissolves hyaluronic acid including molecules made by your body and previous treatments that you may wish to preserve could also be dissolved. You therefore could notice a reduction in skin elasticity and volume and associated asymmetry which typically would last a few days. It is common to cause bleeding, bruising, some swelling or oedema and redness near the injection site.

Yes, I undestand

Treatment Failure: *

It is possible that the procedure will fail to remedy the problem as often HA is not the sole cause of lumps, bumps or reactions, which may be caused by other materials.

Yes, I understand

Complications from infection: *

There is a small risk of introducing an infection, and a theoretical risk that pre-existing infection could spread further if hyaluronidase is injected into the area, risking septicaemia though their are no recorded cases.

Yes, I understand

I confirm I do not have any known allergies to hyaluronidase, and to your knowledge you do not have any active cancers in the area injected and you are not pregnant or breastfeeding. *

I confirm

Follow-up: *

I understand adjustments requiring more product incur a charge.

Yes, I understand

Dissatisfaction: *

I understand that with all treatments the precise degree of improvement cannot be guaranteed. The outcome's subjective nature also means dissatisfaction is a possible outcome regardless of effectiveness of treatment. I understand that the effect of all treatments may gradually wear off, additional treatments may be necessary to acquire the desired effect, and further charges will apply if more product is required.

Yes, I understand

Agreement: *

By signing this form, you agree that you have read this form carefully and considered the side effects, risks and uncertainty of the outcome and decided the treatment is still in your best interests. You have discussed all the details of the treatment plan, past treatments and your medical history with your clinician and shared all the information your clinician may need to plan a treatment. You agree that the balance of the benefits and risks to you overall favour the use of hyalase. You understand that the initial treatment of side effects and complications is included in the cost of the procedure and therefore no refunds are issued due to any of the above occurring. You understand photographs are taken and stored for 7 years as part of my clinical record:

Yes, I understand

Declaration of Consent

I confirm that my treating practitioner has: Provided me with sufficient information about the treatment detailed overleaf in order to make an informed decision – Given me the opportunity to ask all remaining questions I may have about the treatment, and has answered them to the best of their ability – Given me the time to consider the treatment detailed overleaf – Received the relevant medical history information from me to the best of my knowledge I therefore consent to receiving the described treatment by my treating practitioner.

By clicking this I consent to receiving the described treatment by my treating practitioner.

Date Signed *

MM

DD

YYYY