The use, indications, contraindications and potential adverse effects of the treatment with Restylane including product range 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 is a hyaluronic acid of non-animal origin.
*Restylane 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, neck or hands.
*Restylane 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 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 orhypersensitivity 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, Vitamin E, 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 infectionI have informed my HCP about all the medications that I have taken or I am currently taking including herbal medications (i.e. ginseng).
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 as well as the consent to receive injections of Restylane performed by Daniela Bobsin, RN.
I am aware of a 1% adverse reaction possibility with nodule formation in areas where Juverdem (Dermal Filler) from Allergan was injected at an earlier date.
Have you had in the last two (2) weeks any: Immunization, Dental procedure, Infection, and/or Antibiotics?
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.
I HEREBY ACKNOWLEDGE THAT I HAVE FULLY DISCLOSED, TO THE BEST OF MY KNOWLEDGE, MY COMPLETE MEDICAL HISTORY AND HAVE ANSWERED ALL QUESTIONS IN THE MEDICAL HEALTH QUESTIONNAIRE AS HONESTLY AND ACCURATELY AS POSSIBLE. DANIELA BOBSIN BEAUTY MEDICAL AESTHETICS IS NOT RESPONSIBLE FOR ANY ADVERSE EVENTS THAT OCCUR AS A RESULT OF FAILURE TO DISCLOSE HEALTH INFORMATION AS REQUESTED.
I acknowledge that I have had the opportunity to consult with Daniela Bobsin, RN and have asked any questions that I may have related to the procedure I am about to undergo. Daniela Bobsin, RN has reviewed my health history and medications with me, and I agree that I have not withheld any medical information from her or her Nurse Practioner.I have read through and understand all of the information, terms, conditions and complications pertaining to Restylane Dermal Filler Injections, and do herby provide consent to undergo treatment: