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.