CLIENT CONSENT FOR DERMAL FILLER-RESTYLANE

The use, indications, contraindications and potential adverse effects of treatment with the Restylane I range of products have been explained to me. I have answered all questions regarding my medical history truthfully. I have discussed the risks and benefits of Restylane with my healthcare professional (HCP) and have received satisfactory answers.

I clearly understand that:

Restylane I is a hyaluronic acid of non-animal origin.
Restylane I is injected via a syringe into the dermis (skin) or sub-dermis to temporarily correct lines, wrinkle, folds and contours of the face to temporarily increase the volume of the face lips or hands.
Restylne I provides correction for an average of 6 months. The effects varies depending on the type of skin, area of injection, amount injected and injection technique.
The longevity of the effect of the Restylane in the lips may be reduced because of the high vascularization of the lips.
A touch-up procedure a few weeks after the first injection may help increase the persistence and optimize results. A local anaesthetic may be administered as necessary by the HCP

I clearly understand that after injection of Restylane, there are some potential side effects which include and may not be limited to the following:

Inflammatory reactions such as redness, edema and/ or erythema, which may be accompanied by stinging, pain or pressure. These reactions may last up to a week.
Swelling or nodules may develop at the injection site have been reported.
Very rare cased of discolouration the injection site have been reported.
Rare cases, (0.01%), of necrosis in the treated area, abscess, granuloma, blindness or hypersensitivity have been reported after injection of hyaluronic acid, if the injection occludes a blood vessel. Hyaluronidase will be used to dissolve the hyaluronic acid should this event occur.
Persistence of inflammatory reactions for more than one week or the development of any other side effects must be reported to the HCP as soon as possible.
Increase bruising or bleeding at injection site if using substance, such as ASA, fish oils, NSAIDS (Advil, Ibuprofen, Motrin), alcohol or other blood thinning products.

I have informed my HCP of my medical history and I clearly understand that I cannot be treated

with Restylane:

If I am pregnant or nursing
If I have had a cold in the last 2 weeks
If I have a known hypersensitivity to
hyaluronic acid
In areas presenting with inflammation
and/or infectious skin problems (acne, etc.)
If I have a past history of autoimmune
disease

If I am receiving immunotherapy treatments or taking steroids
If I am undergoing laser therapy, chemical peeling, skin tightening treatments or dermabrasion
If I have a tendency to develop hypertrophic scarring
If I have injections of permanent fillers (Dermalive, Artecoll, etc.)
Have chronic sinus infection

CLIENT CONSENT FOR DERMAL FILLER-RESTYLANE

I have read the information provided in the record of consultation for Restylane in its entirely and have discussed the risk and benefits of Restylane with my HCP. I understand the information provided. My HCP have verbally reviewed the consent with me (Initial)

I consent to receive an injection of Restylane (type)

into the area(s)

performed by Daniela Bobsin, RN. I understand that medicine is
not an exact science, and that there can be not guarantees of my results. I further agree to the
written post treatment instructions.

Photographs: I authorize the taking of clinical photographs. These photographs will be only to
be seen by myself, my HCP and staff.

I authorize clinical photographs and their use for scientific purposes in publications, social media and presentations. I understand my identity will be protected. (Initial)

Patient Name

Date

Signature

Clear