Under-eye 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 were you unwell with? *

Please provide 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

Under-eye rejuvenation treatments help reduce under-eye bags and plump up skin to give you a fresher appearance. Dermal fillers are strategically administered to the under-eye area, producing results that can make you look more youthful, less tired and give you more confidence in your appearance. This treatment produces natural, subtle results. You won’t look like you’ve had surgery – you will look relaxed and refreshed.

Under-eye rejuvenation is the perfect way to treat any concerns you have with the under-eye area. We use this treatment for clients of all ages – it might be used to make skin look more youthful, or it might be the perfect remedy for busy, sleep-deprived eyes.

We use this treatment to:

Reduce hollowing under the eye
Reduce under-eye bags
Reduce the appearance of the tear trough and to lighten dark circles
Iron out fine lines and wrinkles

The filler will be administered along the hollow of your tear troughs. A cannula is used to deliver the hyaluronic filler, making it more comfortable. The filler also contains a local anaesthetic to numb the area during treatment – most patients only feel mild, temporary discomfort. The area will then be massaged to make sure the gel filler is evenly distributed.

The treatment will only take around 30 minutes. Results are achieved instantly and we will show you the progress, making sure you are happy and comfortable throughout.

The results will usually last between 12 and 18 months. Once they start to wear off please contact the clinic if you would like to re-book. If you have any concerns at all before this, please do not hesitate to get in touch with our team.

Possible Side Effects

Side effects are very few and very minimal – many of our clients go straight back to work following their treatment.

After treatment, most clients will experience:

Some swelling, which may last around 48 hours
Bruising around the area – the shape of the cannula pushes vessels away, so this should be minimal.

Aftercare Advice

Avoid the following for the first 24-48 hours:

Strenuous exercise
Hot baths or showers
Using a spa or sauna
Drinking alcohol

We also recommend:

Allowing a week before flying as this could prolong swelling and increase the chance of infection
Not having this treatment within two weeks of a special event, so that any bruising can heal fully

Please tick the box to confirm: *

I have read and understood the aftercare advice provided.

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 therapist and/or request to speak to the manager during or immediately following the treatment. I fully understand the above and consent to receive the Under-eye rejuvenation treatment.

Client Signature: *

Tap or click on the signature above to sign