{"id":25,"date":"2020-07-22T01:24:39","date_gmt":"2020-07-22T05:24:39","guid":{"rendered":"http:\/\/myskincareclub.com\/forms\/?page_id=25"},"modified":"2020-07-25T13:18:32","modified_gmt":"2020-07-25T17:18:32","slug":"client-consent-for-dermal-filler-restylane","status":"publish","type":"page","link":"https:\/\/myskincareclub.com\/forms\/client-consent-for-dermal-filler-restylane\/","title":{"rendered":"CLIENT CONSENT FOR DERMAL FILLER-RESTYLANE"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"25\" class=\"elementor elementor-25\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-fa6715b elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"fa6715b\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-24e32bf\" data-id=\"24e32bf\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-e6c9175 elementor-widget elementor-widget-text-editor\" data-id=\"e6c9175\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>CLIENT CONSENT FOR DERMAL FILLER-RESTYLANE<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-ec0a7e5 elementor-widget elementor-widget-text-editor\" data-id=\"ec0a7e5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>The use, indications, contraindications and potential adverse effects of treatment with the\u00a0<span style=\"font-size: inherit; text-align: inherit; letter-spacing: -0.015em;\">Restylane I range of products have been explained to me. I have answered all questions\u00a0<\/span><span style=\"font-size: inherit; text-align: inherit; letter-spacing: -0.015em;\">regarding my medical history truthfully. I have discussed the risks and benefits of Restylane\u00a0<\/span><span style=\"font-size: inherit; text-align: inherit; letter-spacing: -0.015em;\">with my healthcare professional (HCP) and have received satisfactory answers.<\/span><\/p><p>I clearly understand that:<\/p><ul><li>Restylane I is a hyaluronic acid of non-animal origin.<\/li><li>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.<\/li><li>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.<\/li><li><span style=\"font-size: inherit; text-align: inherit; letter-spacing: -0.015em;\">The longevity of the effect of the Restylane in the lips may be reduced because of the high\u00a0<\/span>vascularization of the lips.<\/li><li><span style=\"font-size: inherit; text-align: inherit; letter-spacing: -0.015em;\">A touch-up procedure a few weeks after the first injection may help increase the persistence\u00a0<\/span>and optimize results.\u00a0 A local anaesthetic may be administered as necessary by the HCP<\/li><\/ul><div><div>I clearly understand that after injection of Restylane, there are some potential side effects\u00a0<span style=\"font-size: 1.8rem; letter-spacing: -0.015em;\">which include and may not be limited to the following:<\/span><\/div><div>\u00a0<\/div><div><ul><li>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.<\/li><li><span style=\"font-size: 1.8rem; letter-spacing: -0.015em;\">Swelling or nodules may develop at the injection site have been reported.<\/span><\/li><li><span style=\"font-size: 1.8rem; letter-spacing: -0.015em;\">Very rare cased of discolouration the injection site have been reported.<\/span><\/li><li><span style=\"font-size: 1.8rem; letter-spacing: -0.015em;\">Rare cases, (0.01%), of necrosis in the treated area, abscess, granuloma, blindness or\u00a0<\/span>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.<\/li><li><span style=\"font-size: 1.8rem; letter-spacing: -0.015em;\">Persistence of inflammatory reactions for more than one week or the development of any\u00a0<\/span>other side effects must be reported to the HCP as soon as possible.<\/li><li><span style=\"font-size: 1.8rem; letter-spacing: -0.015em;\">Increase bruising or bleeding at injection site if using substance, such as ASA, fish oils,\u00a0<\/span>NSAIDS (Advil, Ibuprofen, Motrin), alcohol or other blood thinning products.<\/li><\/ul><div><div>I have informed my HCP of my medical history and I clearly understand that I cannot be treated<\/div><div>with Restylane:<\/div><\/div><\/div><\/div>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-16e9590 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"16e9590\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-453ea02\" data-id=\"453ea02\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-1333bf7 elementor-widget elementor-widget-text-editor\" data-id=\"1333bf7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<ul><li>If I am pregnant or nursing<\/li><li>If I have had a cold in the last 2 weeks<\/li><li>If I have a known hypersensitivity to<br \/>hyaluronic acid<\/li><li>In areas presenting with inflammation<br \/>and\/or infectious skin problems (acne, etc.)<\/li><li>If I have a past history of autoimmune<br \/>disease<\/li><\/ul>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-eac4937\" data-id=\"eac4937\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-cd42026 elementor-widget elementor-widget-text-editor\" data-id=\"cd42026\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<ul><li><span style=\"letter-spacing: -0.27px;\">If I am receiving immunotherapy\u00a0<\/span>treatments or taking steroids<\/li><li><span style=\"letter-spacing: -0.27px;\">If I am undergoing laser therapy, chemical\u00a0<\/span>peeling, skin tightening treatments or dermabrasion<\/li><li><span style=\"letter-spacing: -0.27px;\">If I have a tendency to develop\u00a0<\/span>hypertrophic scarring<\/li><li><span style=\"letter-spacing: -0.27px;\">If I have injections of permanent fillers\u00a0<\/span>(Dermalive, Artecoll, etc.)<\/li><li><span style=\"letter-spacing: -0.27px;\">Have chronic sinus infection<\/span><\/li><\/ul>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<div class=\"elementor-element elementor-element-aac962e elementor-widget elementor-widget-wp-widget-frm_show_form\" data-id=\"aac962e\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wp-widget-frm_show_form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"frm_form_widget\"><div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_4_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_clientconsentfordermalfiller-restylane\" >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">CLIENT CONSENT FOR DERMAL FILLER-RESTYLANE<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"4\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_4\" id=\"frm_hide_fields_4\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"clientconsentfordermalfiller-restylane\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_4\" name=\"frm_submit_entry_4\" value=\"7304d70deb\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/forms\/wp-json\/wp\/v2\/pages\/25\" \/><div id=\"frm_field_56_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_vcgbh\" id=\"field_vcgbh_label\" class=\"frm_primary_label\">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)\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_vcgbh\" name=\"item_meta[56]\" value=\"\"  style=\"width:15%\" data-invmsg=\"Text is invalid\" class=\"auto_width\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_50_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_uvs9m\" id=\"field_uvs9m_label\" class=\"frm_primary_label\">I consent to receive an injection of Restylane (type)\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_uvs9m\" name=\"item_meta[50]\" value=\"\"  style=\"width:40%\" data-invmsg=\"Text is invalid\" class=\"auto_width\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_51_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_iynn5\" id=\"field_iynn5_label\" class=\"frm_primary_label\">into the area(s)\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_iynn5\" name=\"item_meta[51]\" value=\"\"  style=\"width:40%\" data-invmsg=\"Text is invalid\" class=\"auto_width\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_90_container\" class=\"frm_form_field  frm_html_container form-field\">performed by Daniela Bobsin, RN. I understand that medicine is<br \/>\nnot an exact science, and that there can be not guarantees of my results. I further agree to the<br \/>\nwritten post treatment instructions.<\/p>\n<p>Photographs: I authorize the taking of clinical photographs. These photographs will be only to<br \/>\nbe seen by myself, my HCP and staff.<\/p><\/div>\n<div id=\"frm_field_52_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_3tbie\" id=\"field_3tbie_label\" class=\"frm_primary_label\">I authorize clinical photographs and their use for scientific purposes in publications, social media and presentations. I understand my identity will be protected. (Initial)\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_3tbie\" name=\"item_meta[52]\" value=\"\"  style=\"width:15%\" data-invmsg=\"Text is invalid\" class=\"auto_width\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_53_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_rec5o\" id=\"field_rec5o_label\" class=\"frm_primary_label\">Patient Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_rec5o\" name=\"item_meta[53]\" value=\"\"  style=\"width:40%\" data-invmsg=\"Text is invalid\" class=\"auto_width\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_54_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_fmm5d\" id=\"field_fmm5d_label\" class=\"frm_primary_label\">Date\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_fmm5d\" name=\"item_meta[54]\" value=\"\"  style=\"width:40%\" maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date auto_width\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_55_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_b80w7\" id=\"field_b80w7_label\" class=\"frm_primary_label\">Signature\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"sigPad\" id='sigPad55' style=\"max-width:400px;\">\n\t<div class=\"sig sigWrapper\" style=\"height:150px;border-color:#BFC3C8;--bg-color:#ffffff;--active:#579AF6;--inactive:#eaeaea;--active-text:#ffffff;--inactive-text:#3f4b5b;--button-margin:22px;--button-size:20px;--button-padding:10px;--button-side-margin:22px;--icon:20px\">\n\n\t\t<ul class=\"sigNav\">\n\t\t\t\t<li class=\"drawIt\">\n\t\t\t\t\t<a href=\"#\" class=\"frm-active-sig-type\" title=\"Draw It\" aria-label=\"Draw It\">\n\t\t\t\t\t\t<svg  viewBox=\"0 0 22 20\" class=\"frmsvg\">\n\t<title>signature<\/title>\n\t<path d=\"M19.7 2.2A3.5 3.5 0 0 0 14 1.1L1.7 13.4a1 1 0 0 0-.3.4l-1.3 5a.9.9 0 0 0 0 .5 1 1 0 0 0 1 .6l5-1.3c.2 0 .4-.1.5-.3L18.9 6a3.5 3.5 0 0 0 .7-3.8zm-6.8 2.6L15.2 7l-8.6 8.7-2.4-2.4zm-10.7 13l1-3.3L5.4 17zM18 4.2l-.4.5L16.3 6 14 3.7l1.3-1.3A1.7 1.7 0 0 1 18 3.6l-.1.6zM9 17.9h11v1H9v-1z\"><\/path>\n\n<\/svg>\t\t\t\t\t<\/a>\n\t\t\t\t<\/li>\n\t\t\t\t<li class=\"typeIt\">\n\t\t\t\t\t<a href=\"#\" class=\"\" title=\"Type It\" aria-label=\"Type It\">\n\t\t\t\t\t\t<svg  viewBox=\"0 0 22 20\" class=\"frmsvg\">\n\t<title>keyboard<\/title>\n\t<path d=\"M20.6 2.5H2c-1 0-1.9.8-1.9 1.9v11.2c0 1 .8 1.9 1.9 1.9h18.7c1 0 1.9-.8 1.9-1.9V4.4c0-1-.8-1.9-1.9-1.9zm.3 13.1c0 .2-.1.3-.3.3H2a.3.3 0 0 1-.3-.3V4.4c0-.2.1-.3.3-.3h18.7c.2 0 .3.1.3.3v11.2zm-14.3-5V9.4c0-.3-.2-.5-.4-.5H5c-.3 0-.5.2-.5.5v1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0V9.4c0-.3-.2-.5-.5-.5H9c-.3 0-.5.2-.5.5v1c0 .3.2.5.4.5H10c.3 0 .5-.2.5-.5zm3.7 0V9.4c0-.3-.2-.5-.4-.5h-1.1c-.3 0-.5.2-.5.5v1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0V9.4c0-.3-.2-.5-.5-.5h-1c-.3 0-.5.2-.5.5v1c0 .3.2.5.4.5h1.1c.3 0 .5-.2.5-.5zM4.8 7.2v-1c0-.3-.2-.5-.5-.5H3.2c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1.1c.3 0 .5-.2.5-.5zm3.7 0v-1c0-.3-.2-.5-.5-.5H7c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0v-1c0-.3-.2-.5-.5-.5h-1.1c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1.1c.3 0 .5-.2.5-.5zm3.7 0v-1c0-.3-.2-.5-.5-.5h-1c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0v-1c0-.3-.2-.5-.5-.5h-1.1c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1.1c.3 0 .5-.2.5-.5zm-2 6.2V13c0-.3-.2-.5-.6-.5h-12c-.3 0-.6.2-.6.5v.6c0 .3.3.5.7.5h12c.3 0 .6-.2.6-.5z\"><\/path>\n<\/svg>\t\t\t\t\t<\/a>\n\t\t\t\t<\/li>\n\t\t<\/ul>\n\n\t\t<span class=\"frm-typed-drawline\"><\/span>\n\n\t\t<div class=\"typed\">\n\t\t\t<input type=\"text\" name=\"item_meta[55][typed]\" class=\"name\" id=\"field_b80w7\" autocomplete=\"off\" value=\"\"  style=\"width:400px\" maxlength=\"150\" class=\"auto_width\" aria-invalid=\"false\"   \/>\n\t\t<\/div>\n\n\t\t<canvas class=\"pad\" data-fieldid=\"55\" data-fieldname=\"item_meta[55]\" width=\"396\" height=\"150\"><\/canvas>\n\t\t<div class=\"clearButton\"><a href=\"#clear\">Clear<\/a><\/div>\n\n\t\t<input type=\"hidden\" name=\"item_meta[55][output]\" class=\"output\" value=\"\" \/>\n\t<\/div>\n<\/div>\n\r\n    \r\n    \r\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_236_container\">\n\t\t\t<label for=\"field_t49ad\" >\n\t\t\t\tIf you are human, leave this field blank.\t\t\t<\/label>\n\t\t\t<input  id=\"field_t49ad\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[236]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"xgbTmpRrvI+5BluaOEpLIiDxedZ0p9CIB+iMTKwhB7zq9oXrtQPMpeG4FaMsnd4G\" \/><div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"  >Submit<\/button>\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>CLIENT CONSENT FOR DERMAL FILLER-RESTYLANE The use, indications, contraindications and potential adverse effects of treatment with the\u00a0Restylane I range of products have been explained to me. I have answered all questions\u00a0regarding my medical history truthfully. I have discussed the risks and benefits of Restylane\u00a0with my healthcare professional (HCP) and have received satisfactory answers. I clearly [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-25","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/pages\/25","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/comments?post=25"}],"version-history":[{"count":6,"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/pages\/25\/revisions"}],"predecessor-version":[{"id":97,"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/pages\/25\/revisions\/97"}],"wp:attachment":[{"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/media?parent=25"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}