Hyaluron Pen Consultation and Consent Form

Client Details

Full Name: *

Date of Birth: *

Email: *

Contact Number: *

Medical History

Are you taking any medication? *

Please list: *

Do you have any allergies or intolerances? *

Please list: *

Are you currently, or possibly may be, pregnant? *

Do you have a history of active cold sores or herpes simplex virus? *

Have you taken Accutane (Isotretinoin) within the past year? *

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

Do you have any other medical conditions? *

Please list: *

Have you been unwell recently? *

Which of the following were you unwell with? *

Please provide more details: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Consultation

Have you had the Hyaluron Pen treatment before? *

If yes, when did you last have this treatment performed? *

Have you had 'traditional', injectable dermal fillers before? *

If yes, why are you switching to the Hyaluron Pen? *

Why are you choosing to undergo this treatment today? *

What are your goals and expectations of the treatment? *

Treatment Information

What is the Hyaluron Pen treatment?

The pen was actually first designed to eliminate the use of needles for those who suffer from diabetes, and has since been used by the beauty industry to allow for no needle fillers.

The pressure from the pen is strong enough to force the filler into the skin.

The active ingredient used, hyaluronic acid, rejuvenates and lifts the lip area, as well as stimulating collagen production.

How the Hyaluron Pen Treatment Works

The Hyaluron Pen (also known as hyaluronic acid pen) is a small handheld medical device that is used to administer hyaluronic acid fillers into the face. This “pen” was originally created for diabetic patients to offer a needle-free, pain-free way to deliver insulin into the subcutaneous tissue.

The Hyaluron Pen works by creating enough pressure external to the tissue to “push” hyaluronic acid filler into the skin without using a needle. It is most commonly being used for lip injections.

Advantages of the Hyaluron Pen Treatment

Hyaluronic acid is a natural chemical
Significantly reduced pain and bruising compared with other treatments
Instant results
No downtime
Plumper and more hydrated lips
Great for clients who suffer from trypanophobia (fear of needles)

Patients that may not be eligible for the treatment

Due to certain health conditions, some may not be allowed or may be evaluated further to take this treatment. This is for the protection of the health and safety of the patient. We have enumerated here the following conditions that may prevent the patient to undergo the Hyaluron Pen treatment and thus the practitioner must be notified:

Allergic reactions to hyaluronic products
Anaphylactic or a history of a serious allergic reaction
Keloid formers
Pregnant or nursing a child
Recent dental/facial surgery
Viral infections such as herpes or simplex (cold sores)
Under certain medication

Is it safe?

As with all treatment procedures, there is always a potential risk, however it is minimal with the Hyaluron Pen. Some clients might experience swelling, bruising or blood spot right after the treatment.

How long does this treatment last?

The average duration for results is 3-7 months, however your lifestyle and metabolism will have a factor in the longevity of the hyaluronic acid.

Aftercare Advice

Your lips will likely be swollen after the procedure. You may also notice some redness or bruising at the injections sites, which is normal. Most side effects will be minor, and you will be able to resume most activities once the procedure is done.
Apply ice to your lips using an ice pack or an ice cube covered in cloth (so it doesn’t stick to the lip and cause pain). This will help ease swelling, itching, bruising, and any other pain.
Avoid strenuous exercise for 24 to 48 hours after you get lip or any other dermal fillers. Elevated blood pressure and heart rate from exercise may make swelling or bruising worse. It’s fine to engage in light activity like walking.
Stay hydrated. Drinking plenty of water will help your body heal. Hyaluronic Acid is also a humectant (attracts water) so drinking plenty of water will lengthen the life of your fillers.
Eat plenty of hydrating fruits and vegetables and try to avoid excess sodium, which may worsen swelling. Eat fresh pineapple, as it contains bromeliad that has been known to decrease bruising.
Avoid high temperatures like steam rooms, saunas, or heated exercise classes for 48 hours after treatment. High heat can make swelling more pronounced.
Ask your doctor which painkillers are OK to take in the days after your treatment. Paracetamol are fine, but not blood-thinning medications like Ibuprofen or Aspirin.
Avoid the following for a few days after your treatment - Aspirin, NSAIDS (Ibuprofen, Aleve, Motrin etc) St John's Wort, Vitamin E, Multivitamins, Krill Oil, Fish Oils, Flaxseed Oils, Omega-3, Gingko, Ginseng, Garlic & Glucosamine - These all thin the blood so can cause bleeding or bruises.
Try to sleep with your head elevated on pillows to reduce swelling. Do not sleep on your face.
Avoid makeup on your lips for at least 24 hours after.
Alcohol acts as a blood thinner and should be avoided for at least 24 hours after getting lip fillers. Alcohol can cause inflammation, increase the likelihood of bruising, and make swelling worse. It’s also a good idea to avoid alcohol a few days before your appointment. too.
Avoid flying for 1 week following your procedure. This is because the air pressure in a plane can make swelling and bruising worse.
If you’re getting lip fillers for a specific event, make sure to leave plenty of time in between the procedure and the event to allow your lips to properly recover.

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

I fully understand the above and consent to receive Hyaluron Pen treatment.

Client Signature: *

Tap or click on the signature above to sign