By using the WaiverElectronic system, you can fill out a digital medical waiver form easily.
Informed consent form - Hyaluronic acid dermal filler treatment
- To be completed by Practitioner
This treatment uses dermal filler which consists of hyaluronic acid, for injection into the skin to correct facial lines, wrinkles or folds, for lip enhancement and for shaping the facial contours. The dermal filler conforms to the current safety standards in the UK. It is a non-permanent procedure and a repeat procedure may be required to maintain the results.
The area(s) we are proposing to treat is/are: (To be completed by Practitioner)
Consent
The methods of us and indications of this product have been explained to me by the practitioner and I have had the opportunity to have all questions answered to my satisfaction. I have been specifically informed of the following:
Common side effects associated with the injection
Pain or stinging sensation when the injection is performed; localised 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 and may inhibit your confidence to attend work or social events. You are advised to schedule treatments with this in mind, allowing time for common reactions such as bruising and swelling, to settle.
Uncommon side effects
Infection; inflammation; skin discolouration (which may occur within a few days or weeks to months following treatment); allergic or sensitivity reaction, which may be local (redness, itching or rash at the site of treatment) or may be severe requiring hospital treatment, abscess formation; a foreign body reaction, known as 'granuloma' presenting as lumps or nodules; the blood supply to the skin maybe interrupted by swelling or inadvertent injection into a vessel, causing pain, skin damage and possible scarring.
Correction is expected to last for a period of 4-12 months. The successful outcome varies by degree and how long it lasts varies from one individual to another and cannot be guaranteed. There maybe. knock on effect from the treatment on other areas of the face. I understand if I suffer from any adverse reactions that are not expected, or concern me, I must contact Emma Illidge. Emma Illidge cannot take responsibility for complications or results that have not been reported, assessed, documented and managed in a timely fashion. I confirm that the medical history form has been completed truthfully and I am fully aware that withholding medical information, including history of previous treatment, maybe 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. I agree to follow the after are advice and understand this reduces risk of adverse reactions and helps ensure optimism results.
I hereby authorise Emma Illidge of Glo Contour Clinic, who is an experienced and qualified aesthetic practitioner to administer the above treatment to me and I agree to hold her free and harmless from any claims, or suits or damages for any injury or complications that are a result from this treatment.
