Botulinum Toxin (BOTOX) & Dermal Fillers PATIENT CONSENT FORM

Please complete the following questions

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MEDICAL HISTORY

Please complete the following medical questionnaire.  

Have you suffered from or have any of the following conditions?

Please complete the following Hyaluronidase (Hyalase) form below. This form is a record of your decision to consent to a procedure having considered the risk of both positive and negative outcomes and medical risks listed below, and the impact they may have on your well-being. The doctor during the consultation will be happy to answer and questions or concerns you may have. Please carefully read the information below and by ticking the boxes you consent to understanding the associated risks with the treatment. What is being injected? Hyaluronidase is an enzyme that breaks down dermal fillers made of Hyaluronic acid into small sugars which easily disperse. Risks of the procedure include but may not be limited to:
I understand the information on this form is essential to determine my medical and cosmetic needs and the provision of treatment. I understand that if any changes occur in my medical history/health I will report it to the office/clinic as soon as possible. I have read and understand the above medical history questions. I will ask any information I am unceratin about before or during my appointment.  I acknowledge that all answers have been recorded truthfully, correctly, to the best of my knowledge and will not hold any staff member responsible for any errors or omissions that I have made in the completion of this form.

INSTRUCTIONS This is an informed consent document that has been prepared to help inform you concerning Botox injections and the risks involved. It is important that you read this information carefully and completely. Please tick each page, indicating that you have read the page and sign the consent at the bottom prior to your treatment. INTRODUCTION BOTOX injections involve a series of small injections in order to weaken the chosen muscles for example on the brow or below the eyes. Weakening of the injected muscles begins to be apparent after 2-3 days with the peak effect being reached after 10-14 days. Results can last 3-9 months. The procedure can be repeated after 3 months; however, injections given less than 3 month intervals may reduce the efficacy of the injections. RISKS OF BOTOX INJECTIONS Every procedure involves a certain amount of risk, and it is important that you understand that risks involved. An individual’s choice to undergo a procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience these complications, you should discuss each of them with your practitioner to make sure you understand the risks, potential complications, and consequences of BOTOX injections: Unsatisfactory Outcome/Temporary loss of function of nearby muscles Temporary Double Vision/ Migraine Hypersensitivity, Allergic response, Anaphylactic reaction (rare but can occur) Asymmetry of facial expressions Muscle weakness, twitching Bruising/swelling/skin redness Stinging/burning Headaches Drooping of the eyelid or eyebrow (ptosis)/local muscle weakness, double vision, dry/teary eyes Hives, feeling faint, nausea or flu like symptoms, tiredness Swelling of the face or throat, dry mouth, difficulty swallowing Infection at treatment site Period to take effect, further treatment needed, remaining muscle movement General Complications: Stinging/tingling/burning/bruising/swelling Injection site bleeding/skin redness around treatment area

NSTRUCTIONS This is an informed consent document that has been prepared to help inform you concerning Dermal Filler injections and the risks involved. It is important that you read this information carefully and completely. Please initial each page, indicating that you have read the page and sign the consent at the bottom prior to your treatment. INTRODUCTION Dermal fillers are used to correct volume loss, shape, contour and reduce the appearance of fine and/or deep lines. They consist of Hyaluronic acid which is a naturally-occurring gel produced in the body, which is injected into the treatable area. Fillers consist of local anaesthetic gel which minimises discomfort. The results can often be seen immediately after injection and can last anything between 6-18 months. RISKS OF DERMAL FILLER INJECTIONS Every procedure involves a certain amount of risk, and it is important that you understand that risks involved. An individual’s choice to undergo a procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience these complications, you should discuss each of them with your practitioner to make sure you understand the risks, potential complications, and consequences of dermal filler injections: Hypersensitivity, Allergic response, Anaphylactic reaction (rare but can occur) Formation of nodules (lumps) around the treated area Slight visibility/palpability of the product under the skin Persistent bruising/ swelling which may last up to several weeks Infection/abscess formation following treatment, eruption of cold sores Small/Very Rare possibility of filler being injected into a blood vessel which could lead to blockage of the blood flow to the area supplied by the blood vessel (Vascular Occlusion) causing skin soreness, pain, coldness, numbing and discoloration. Please contact the clinic as soon as possible in this instance on 07379027375 or email- tiara.aesthetics@gmail.com. Perfect symmetry may not be achievable. Limited or non-response to treatment or Unsatisfactory Outcome Extremely rare risk of blindness if filler is injected into certain anatomical sites, such as the Glabella, Nasolabial folds and the Nose. The doctors will discuss this during the consultation and provide advice on what to do post treatment(s). If you are not sure please ask anything listed above during your consultation or prior to your consultation with one of our staff memebers, who will help advise and guide you.

INTRODUCTION Profhilo/Sunekos is a product containing hyaluronic acid and amino acids. It is used to smooth out wrinkles, hydrate the skin, and improve skin texture that has lost its volume and fulness due to ageing, sun exposure, illness etc. This particular combination of HA and amino acids helps to stimulate the extracellular matrix of the skin. Facial rejuvenation can be carried out with minimal complications. Treatment may require a course of 1-3 sessions, each 1 month apart and the results can often be seen 3 days after injection and last between 6-12 months, results vary according to which skin booster is performed and vary person to person. Please consult our practitioners if you have any questions or queries regarding treatments. RISKS OF PROFHILO INJECTIONS Every procedure involves a certain amount of risk, and it is important that you understand the risks involved. An individual’s choice to undergo a procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience these complications, you should discuss each of them with your practitioner to make sure you understand the risks, potential complications, and consequences of Profhilo/sunekos injections: • During and Post treatment discomfort • Bleeding • Bruising/Swelling • Numbness or itching • Inflammation • Infection • Lumpiness • Skin discolouration • Localised necrosis if blood vessel occlusion occurs CAUTIONS & CONTRAINDICATIONS (To be checked with patient prior to treatment) • Known hypersensitivity to ingredients or any of its excipients e.g. Lidocaine • Anticoagulant use (e.g. Warfarin/Aspirin) • Pregnancy/Breastfeeding • Infected skin area e.g. cold sores/cellulitis etc I declare to be duly informed about use, indications, contraindications, possible adverse reactions and complications regarding the use of skin boosters mentioned above. I certify that the answers to the questions regarding my general health, and previous aesthetic and medical treatments are accurate and correct the best of my knowledge. I have been given an opportunity to ask questions and have had them fully answered. Furthermore, I understand that: – this product is a clear bio-reabsorbable hyaluronic acid gels of non animal origin. – The duration of the results may vary depending on skin type, treated area, quantity injected and injection techniques. I understand that after treatment with the above-mentioned product: Incidents of inflammatory reactions (erythema, oedema, etc) sometimes associated with itching and pain to the touch may occur. These reactions may persist for 7/10 days. Hardening or nodules may appear at the point of injection. I was also informed about very rare cases, as described in literature, of discoloration at the injection point, necrosis of glabellar area, abscess, granuloma and hypersensitivity, after hyaluronic acid injections. If the inflammatory reactions persist more than 7-10 days, I must contact my physician immediately. I also declare that I am aware of the advice to follow during the post-injection period which I will follow correctly. Having been properly informed, and having completely understood the advantages of the above mentioned treatment/s and eventual adverse reactions that may occur.

I have read a copy of the foregoing consent for the procedure, understood the side effects and possible complications related to my treatment, accept these facts, and hereby authorize Tiara Aesthetics to perform the procedure of Botulinum Toxin/ Dermal Filler injections. Please Note: Due to the subjective nature of the treatment it is not possible to guarantee results. Longevity of treatment results may vary between individuals. Patients can react differently to the same treatment. List of possible risks and complications is not exhaustive. My medical practitioner will take photos or videos taken before or after my treatment for the purposes of my medical records. I agree to these photos being kept confidentially with my medical file and agree to photos being taken.

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