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
  • 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
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.