Hand Rejuvenation Consultation and Consent Form

Client Details

Full Name: *

Date of Birth: *

Email: *

Contact Number: *

Medical History

Are you currently taking any medication? *

Please list: *

Do you have any allergies or intolerances? *

Please list: *

Are you currently (or possibly may be) pregnant or breastfeeding? *

Do you have any of the following? Please tick all that apply.

Epilepsy Hypertrophic Scarring Cardiac Conduction Disorder

Do you have any other medical conditions? *

Please list: *

Have you recently been unwell? *

Which of the following have you been unwell with? *

Please provide more detail: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Consultation

Do you smoke? *

Have you had any treatment with dermal fillers (e.g. Absorbable dermal fillers, Semi permanent dermal fillers, or Botulinum toxin)? *

Which treatment(s) have you received, which areas were treated, and when did you receive the treatment(s)? *

Have you ever suffered from an auto-immune disease or any condition affecting the immune system? *

Please specify: *

Do you have any cutaneous (skin) infection or inflammatory problems (e.g. herpes/cold-sores, acne etc.)? *

Please specify: *

Are you taking any steroids, aspirin or anticoagulants (i.e. warfarin, apixaban etc.)? *

Please specify: *

Do you suffer from acute rheumatic fever or recurrent sore throat? *

Please specify: *

Have you ever experienced a reaction to hyaluronic acid, amide type local anaesthetics or lidocaine? *

Please specify: *

Treatment Information

What is hand rejuvenation treatment?

As you get older, the skin on your hands is one of the first areas to show signs of ageing. The skin becomes thinner and is subject to daily wear and tear. Your hands lose volume, fat and elasticity, especially after the menopause, becoming translucent and shrivelled so that tendons and veins show more easily and age spots can appear. The loss of muscle bulk between fingers creates hollows, making hands look bony.

The skin on your hands is naturally thin but becomes thinner and rougher with time and with constant exposure to the sun and the elements.

An anti-ageing hand lift for smoother, fresher-looking skin and less prominent hand veins can be achieved through dermal filler treatment. The treatment is progressively rejuvenating and long-lasting with natural looking results.

It is an injectable dermal filler with a unique mode of action. It corrects wrinkles on hands by adding volume to regain skin elasticity; it also works as a collagen stimulator, giving skin an immediate lifting and contouring effect.

Young skin has volume, elasticity and strength due to its natural collagen. The treatment contains calcium-based microspheres (CaHA) to stimulate the production of the body’s own collagen for sustained effects.

What can hand rejuvenation treatment be used for?

Hand rejuvenation improves the quality and texture of your skin while decreasing wrinkles and prominent veins.

A hand lift is an injectable dermal filler and collagen stimulator with a precise mode of action to correct volume loss in the back of wrinkly hands and improve skin quality.

How soon will I notice the results?

The treatment provides an immediate lifting and tightening effect for volume with visible rejuvenation. Because it also acts as a collagen stimulator, results are progressive and long lasting.

How long does a hand lift treatment last?

The unique formulation of the treatment stimulates the production of new collagen, with a lifting and contouring effect that can last up to one year or more.

Does hand rejuvenation treatment hurt?

There is very little pain associated with this treatment as the needles used are every small and the products used contain lidocaine, which numbs the area to maximize comfort of each patient.

Is there any downtime after hand rejuvenation treatment?

There is no downtime needed after this simple, quick and very effective treatment.

What are the most common adverse effects after hand rejuvenation treatment?

Soreness, bruising, swelling are the most common adverse effects after the procedure. The swelling may increase over the next 24 hours, causing pressure and sore feeling in the hands, but it is temporary.

Aftercare Advice

After the treatment(s) some common injection-related reactions may occur, such as swelling, redness, pain, itching, discoloration and tenderness at the injection site but generally they are not significant. These typically resolve spontaneously within 2 to 10 days.

Mild bruising or a slight blush might appear at the injection site immediately following treatment and may last for 2-10 days.

All of the below increase bruising. To avoid swelling and bruising, you should avoid taking:

Aspirin
Exedrin
Ibuprofen
Aleve or Advil for 1 week before and 2 days after
Paracetamol/Tylenol is fine
Vitamin E (or multivitamin) or St. John’s Wort for 2-3 days before or after
Avoid exercise, except for walking, for 24 hours after the procedure

Please tick the box to confirm: *

I have read and understood the aftercare advice given to me on this form.

Consent

I accept that any treatment I am going to receive is at my own risk.

I certify that I have read, 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), unknown because of this to which I accept full liability/responsibility.

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 therapist and/or request to speak to the manager during, or immediately following, the treatment.

I fully understand the above and consent to receive Hand Rejuvenation treatment.

Client Signature: *

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