Dermal Fillers - Injectables

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First Name *

Last Name

Date of birth (DD-MM-YYYY) *

Phone *

Email *

Gender *

Male

Female

Other

Address

Street Address *

City *

State *

Postal code *

Medical History

Is there any chance you could be pregnant/Breastfeeding? *

Yes

Do you have any medical problems?

Are you taking any medication?

Yes

Have you taken aspirin, warfarin or ibuprofen within the last week? *

Are you undergoing any dental treatment? *

Do you have any allergies? *

Have you ever had a severe allergic reaction (anaphylaxis)? *

Yes

Have you ever had facial surgery? *

Have you taken Roaccutane (for acne) in the past 12 months? *

Do you suffer from keloid scarring? (overgrowth of scar tissue)? *

Are you prone to bruising? *

Yes

Do you suffer from herpes(cold sores)? *

Have you had any skin peels, injections or laser treatment? *

Have you previously had filler treatments? *

Do you suffer from any skin infections/ problems? *

Do you have a history of auto-immune disease? *

I confirm that I have answered this to the best of my ability.

Full Name *

Signature *

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Date *

Informed Consent – Dermal Fillers

Ø I confirm that I consent to receiving treatment using hyaluronic acid filler.

Ø I have been given sufficient information to enable me to understand the use of the product.

Ø Some redness, swelling, haematomas or bruising may occur following treatment. These will usually resolve within a few days.

Ø As with all injectable treatments, there is a minimal risk of infection, vessel occlusion, granuloma, abscess formation and hypersensitive reaction.

Ø I agree to the use of a topical anaesthetic cream.

Ø I agree to follow the post-treatment advice given to me by my practitioner.

Ø I understand that the practice of medicine and surgery is not an exact science and therefore that no guarantee can be given as to the results of the treatment referred to in this document. I accept and understand that the goal of this treatment is improvement, not perfection, and that there is no guarantee that the anticipated results will be achieved.

Consent to the treatment detailed on this form.

I give consent for my photos to be used for marketing/ advertising purposes *

Yes

*Signature* *

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Our aim to provide incredible results in affordable prices.

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