Consent Forms

- AestheticS -

Skin Boosters - Consent Form

First name

Last name

Address

Phone

Birthday

Month

Day

Year

Marketing

We would like to contact you with special offers, related products and relevant services. If you consent for this purpose, tick you preference:

Tick your preference

SMS

N/A

Photographs taken shall be part of the medical record and used for documentation of response to treatment. With explicit permission these photographs may also be used for educational purposes or for client information.

Multi choice

Yes, I agree

As part of the marketing activity (digital and/or print) we would like to use anonymously before & after photos of your treatment for use to promote this treatment.

Multi choice

Yes, I agree

Introduction to Skin Boosters.

I confirm I have seen aesthetic practitioner for a medical health check prior to today's treatment.

Multi choice

Yes, I agree

Please sign here:

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THE TREATMENT

SKIN BOOSTERS are injectables that improve skin texture, elasticity, hydration and overall appearance. Treatment involves injecting hyaluronic acid (HA) which is a soft, gel – like substance under the skin, which improves the skin’s elasticity, firmness and radiance giving an overall skin quality. Skin boosters are often called skin quality as they improve and enhance the overall quality and health of the skin.

RISKS AND COMPLICATIONS: Understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalisation, and/or extended outpatient therapy to permit adequate treatment. It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and this specific instance such risks include but are not limited to 1) Post-treatment discomfort, swelling, redness, bruising, and discolouration; 2) Post-treatment infection associated with any transcutaneous injection; 3) Allergic reaction; 4) Reactivation of herpes (cold sores); 5) Lumpiness, visible yellow or white patches; 6) Granuloma formation; 7) Localised necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs.

I hereby indemnify the practitioner from any liability relating to the procedures that I am having. I also understand that any treatment performed is between me and the practitioner who is treating me and I will direct all post-operative questions or concerns to the practitioner.

Yes understand the treatment please sign here:

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The possible side effects of Skin Boosters include but are not limited to:

BLEEDING & BRUISING: It is possible, though unusual, to have a bleeding episode from aSkin Booster injection during the procedure. Bruising in soft tissues may occur. Should youdevelop post-injection bleeding, it may require emergency treatment or surgery. Aspirin, anti-inflammatory medications, platelet inhibitors, anticoagulants, Vitamin E, ginkgo biloba and other "herbs / homeopathic remedies" may contribute to a greater risk of a bleeding problem. It is recommended not to take any of these for seven days before or after Skin Booster injections.

SWELLING: Swelling (oedema) is a normal occurrence following the injections. It decreases after a few days. If swelling is slow to resolve, medical treatment may be necessary.

ERYTHEMA (Skin Redness): Erythema in the skin occurs after injections. It can be present for a few days after the procedure.

NEEDLE MARKS: Visible needle marks from the injections occur normally and resolve in a few days.

ACNE-LIKE SKIN ERUPTIONS: Acneiform skin eruptions can occur following the injection of tissue fillers. This generally resolves within a few days.

SKIN LUMPINESS: Lumpiness can occur following the injection of Skin Booster. This tends to smooth out over time. In some situations, it may be possible to feel the injected tissue product material for long periods of time.

VISIBLE TISSUE MATERIAL: It may be possible to see any type of tissue product material that was injected in areas where the skin is thin.

PAIN: Discomfort associated with Skin Booster injections is normal and usually of short duration.

SKIN SENSITIVITY: Skin rash, itching, tenderness and swelling may occur following Skin Booster injections. After treatment, you should minimize exposure of the treated area to excessive sun or UV lamp exposure and extreme cold weather until any initial swelling or redness has gone away. If you are considering laser treatment, chemical skin peeling or any other procedure based on a skin response after Skin Booster treatment, or you have recently had such treatments and the skin has not healed completely, there is a possible risk of an inflammatory reaction at the implant site.

Yes I understand the side-effects please sign here:

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RESULTS

SKIN BOOSTERS area a safe and effective when compared to collagen skin implants and related products to fill in wrinkles, lines and folds in the skin on the face. Its effect can last

up to 6 months. However, there is no guarantee that you will be completely satisfied. There is no guarantee that you will not require additional treatment to achieve the results you seek. The procedure is temporary and additional treatments will be required periodically, generally within 3 - 6 months. I am aware that follow-up treatments will be needed to maintain the full effects. I am aware the duration of treatment is dependent on

many factors. I have been instructed in and understand the post-treatment instructions. The results may need a downtime period of up to 2-4 weeks of recovery.

Yes I understand & agree, please sign here:

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MEDICAL HISTORY & CURRENT MEDICAL CONDITIONS

Please check any health conditions which you have ever had previously or are now experiencing. (If Yes to any of the following please detail in the box below)

Are you currently in good health?

YES

Do you carry a warning card, an EpiPen, or have you ever had an anaphylaxis reaction?

YES

Are you currently under a specialist, hospital or doctor's care?

YES

Do you use ANY medication, herbal/natural supplements or topical creams on a regular basis?

YES

Do you have ANY allergies to medications, food, latex, or other substances?

YES

Have you had any cold sore breakouts (oral herpes) in the past year?

YES

Do you have a history of Keloid Scarring?

YES

Any blood-borne diseases?

YES

Are you, or could you be pregnant?

YES

Are you breastfeeding?

YES

Are you going through IVF?

YES

Any recent vaccinations (including Covid), cortisone injections or steroids?

YES

Replacements, implants, operations, X-rays recently?

YES

Any other diseases, illnesses or treatments?

YES

Do you suffer with Acne, or have you taken medication for Acne in the past 6 months?

YES

Have you ever had cancer?

YES

Do you have ANY current or chronic medical illness, including: Myasthenia Gravis, Amyotrophic Lateral Sclerosis or any other Neuromuscular disorders?

YES

Add your text

Do you have an autoimmune disease? (e.g. Crohn's disease)

YES

A stroke or any other blood pressure problems?

YES

Deep skin peeling?

YES

AIDS/HIV?

YES

Asthma, Eczema or other allergic disease?

YES

Angina, murmur, valve or other heart conditions?

YES

Have you ever had eyelid or facial surgery?

YES

Any neurological conditions such as epilepsy, Bell's Palsy, MS, Chorea or Myasthenia Gravis?

YES

Jaundice, Hepatitis, Liver or kidney disease?

YES

Current Medical Status

1. Taking medicines, pills, tablets, ointments or inhalers?

YES

If YES, please tell us which:

2. Use therapies or Supplements such as St. John’s Wort?

YES

If YES, please tell us which:

3. Do you bruise or bleed easily?

YES

4. Any circulative problems or varicose veins?

YES

5. Any endocrine disorders? (Diabetes, thyroid)

YES

If YES, please tell us which:

6. Do you follow a healthy diet?

YES

7. Do you take regular exercise?

YES

8. Fluid intake - please tick:

Water

HerbalTea

Alcohol

Coffee /Tea

9. Have you had electrical facial treatments before?

YES

By signing below l acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks.

Yes consent - please sign here:

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Have you previously received BOTOX/ DERMAL FILLER injections?

YES

If YES, please tell us when, area treated, any previous adverse reactions:

I understand this is an elective procedure & the procedure has been fully explained to me. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history I will notify the professional who treated me immediately. I also state that I read and write in English.

I certify by signing this form that you have read the information in this document and completely understand it. I choose to proceed based entirely on the information provided in this informed consent document. You have been given all the necessary opportunities for discussion and all your questions regarding Skin Booster injections have been answered. I therefore and hereby consent to the care or treatment described herein.

Signature

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PRACTITIONER ONLY

I confirm that I have fully informed the patient about the risks and benefits of treatment with Botulinum Toxin and believe they understand all the information given.

They have also been informed of alternative treatment for their presenting complaint.

Practitioner Name:

Practitioner Signature:

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Date

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