Dermal Filler Dissolving Treatment Consultation and Consent Form | Webform Portal

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Hyaluronic Acid Dermal Filler Dissolving Treatment Consultation and Consent Form

Client Details

Client Name: *

Date of Birth: *

Email: *

Contact Number: *

Medical History

Are you currently taking any medication? *

Please specify: *

Are you pregnant, planning a pregnancy or breast feeding? *

Have you a history of severe allergy / anaphylaxis? *

Please specify: *

Do you have any medical conditions? *

Please specify: *

Do you have any allergies or intolerances? *

Please specify: *

Consultation

Did we administer your filler? *

When did you last have filler administered? *

What is the reason for having the filler dissolved? *

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Treatment Information

What's involved?

Hyaluronic acid dermal fillers can be dissolved using an enzyme called Hyaluronidase. This enzyme naturally occurs in our skin but can be injected at higher concentrations in order to rapidly remove unwanted filler. The enzyme is a powder that is mixed with saline and then this solution is injected directly into the area where the filler has been placed, dissolving any unwanted dermal filler. The procedure can be repeated if needed. The filler will be broken down and will disappear in a matter of minutes. However, the results of the treatment are usually only apparent after 24 hours (once any swelling has gone down).

If your filler is non-hyaluronic acid, then this treatment will not work. Non-hyaluronic acid fillers cannot be dissolved and can only be surgically removed.

How many sessions?

Our aim is to inject the minimum necessary dose of enzyme to dissolve the unwanted filler, but not to dissolve natural hyaluronic acid in the skin. For this reason, we only inject small quantities of enzyme per treatment. This means that more than one treatment may be required in order to fully remove the unwanted filler.

Is it painful?

Dissolving filler is not painful. We provide numbing cream, numbing injections and skin cooling to minimise any discomfort.

Side effects

As with any injection, it is possible that you may experience some redness, swelling, tenderness and bruising. These may take a 2-3 days to resolve and bruises sometimes longer. We advise that you don’t plan treatments around important commitments and allow at least 2 weeks between treatment and an important social or work event.

How to prepare

We recommend that you avoid taking blood thinning tablets such as aspirin or ibuprofen (unless prescribed by your doctor) for 3 days prior to treatment. We also advise avoiding alcohol intake for 24 hours prior to treatment. It is also important that you are available for follow-up after treatment, so we recommend not to book injectable treatment if you are travelling in the next two weeks.

Consent

Please read each statement carefully and tick to show your agreement. *

I accept that any treatment I am going to receive is at my own risk. I certify that I have read and fully understood and completed this form to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect(s) and therefore I accept full liability/responsibility for the information given. The treatment(s) and possible side effect(s) have been fully explained to me. I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request. I accept that if I am not satisfied with the treatment I will inform the practitioner and/or request to speak to the manager during or immediately following the treatment. I fully understand the above and consent to receive a Dermal Filler Dissolving treatment.

Client Signature: *

Tap or click on the signature above to sign

Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.

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