Dermal Filler Dissolving Treatment Consultation and Consent Form

Client Details

Client Name: *

Date of Birth: *

Email: *

Contact Number: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Medical History

Are you currently taking any medication? *

Please specify: *

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

Pregnant Planning a pregnancy Breastfeeding None

Have you a history of severe allergy / anaphylaxis? *

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Do you have any medical conditions? *

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Do you have any allergies or intolerances? *

Please specify: *

Have you been unwell recently? *

Which of the following were you unwell with? *

Please provide more detail: *

Treatment Information

Hyaluronic acid dermal fillers such as Juvederm, Restylane, Teosyal and Belotero 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 into the area where the filler has been placed. 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). More than one treatment may be required in order to fully remove the unwanted filler.

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

Possible 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.

Pre-Treatment

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 2 weeks.

Aftercare Advice

Please take a moment to read the aftercare advice.

For the 24 to 48 hours following your dissolving treatment there will be some redness and swelling in the treated area.

It’s recommended to book your appointment either in the evening or on a day that you have no other plans.

After your treatment we advise you to do the following:

Avoid using makeup for 12 hours post-treatment.
Avoid facial scrubs or rubbing the area for 24 hours post-treatment.
Avoid sunbathing and direct sunlight for 24 hours post-treatment.
Avoid swimming for 24 hours post-treatment.
Avoid strenuous exercise for 24 hours post-treatment.
Avoid any excessive alcohol use for a day after your treatment.
Avoid using any skincare which has active ingredients for the next 3 days. This includes Beta Hydroxy Acid, vitamin C, retinols, or Alpha Hydroxy Acids.

Please tick the box to confirm: *

I have read and understood the aftercare advice provided to me.

Consent

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 immediately.
I fully understand the above and consent to the treatment.

Client Signature: *

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