MEDICAL HISTORY AND CONSENT FORM FOR DERMAL FILLERS

  • Please note that this medical consent form will be kept confidential and will only be viewed by the Practitioner responsible for you whilst undergoing treatment at this Cosmetic Injectable Clinic. Your details will not be available to third parties. If any of the answers on this consent form raise a concern for the Cosmetic Injectable Practitioner responsible for your safety, you may be contacted to discuss further or these may be discussed at the time of your consultation. We won’t share your details with anyone not directly involved in the running of this clinic.

  • Personal Information

  • Medical History

    (Because Botulinum Toxin softens wrinkles through its effect on muscles, it is important that you avoid treatment with Botulinum Toxin around the mouth if you play either of these families of instruments).
  • Have you suffered from or had any of the following conditions?

    This is more common in dark-skinned individuals
  • I hereby consent to the following:

  • Optional

  • IMPORTANT TO NOTE

    Dermal Filler is the synthetic form of a natural substance found in human tissues (Hyaluronic Acid). It can be injected directly beneath the skin to provide cosmetic benefits. It is effective immediately and can last from 6-12 months. After treatment, you are advised to avoid wearing makeup over the injection sites for 12 hours to reduce the risk of skin infection. Potential complications and side-effects of filler include:

    • Bruising, bleeding, discomfort, itching for several days.
    • Rarely discolouration of the injection site, necrosis (death of skin), abscess formation, granulomas (abnormal growth of skin), hypersensitivity and haematomas (large bruises) have been reported. Indurations or nodules may develop at the injection site — if any of these symptoms persist for more than 1 week, consult with the doctor/dentist/nurse who has treated you.
    • When using dermal filler to treat frown lines, smile lines (nasolabial / nose-mouth lines) there is a very small risk of skin damage requiring plastic surgery or even irreversible blindness. Feel free to ask your practitioner what precautions they will take to minimise this risk.

  • I acknowledge the following statements: