BOTOX, Filler and Hyalase Consent
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Healthspan Medical PTY LTD
CONSENT FORM – Botulinum Toxin
INFORMED CONSENT
I confirm I have been informed that:
Botulinum Toxin is approved for the treatment of glabellar lines (frown lines between the
eyebrows), forehead lines and lateral canthal lines (crow’s feet lines) and is injected into the skin to
help correct wrinkles. Possible things that could happen when, or after, the product is used, if they
occur, usually appear within the first few days following injection, and are usually temporary and
mild to moderate in severity. As with any prescription medicines, Botulinum Toxin can cause side
effects and your doctor will advise you about these in more detail. The most common side effects
associated with the use of Botulinum Toxin are headaches, eyelid ptosis (drooping of upper eyelid),
eyelid oedema, brow ptosis, skin tightness, facial pain and paresis, and muscle weakness to
surrounding muscles. As with any injection, pain, burning, stinging, swelling, redness and/or
bleeding/bruising may occur. Patients treated with recommended doses of Botulinum Toxin may
experience complete muscle weakness.
If you are worried about any side effect you think you may be experiencing, or the duration thereof,
contact your doctor as soon as possible to discuss this and to obtain medical advice or treatment if
needed. Side effects possibly related to the spread of toxin distant from the site of administration
have been reported very rarely with botulinum toxin (e.g. exaggerated weakness in other muscles in
your body not near to where the injection was given, difficulty in swallowing or pneumonia due to
unwanted food or liquid in the airways, which can be fatal). A severe allergic reaction may occur very
rarely after the injection of Botulinum Toxin. If you experience any of the above, contact your
medical doctor immediately to obtain medical advice and/or attention.
Injection of Botulinum Toxin is not recommended in patients with a history of dysphagia (difficulty in
swallowing). Contact your medical doctor and seek medical attention immediately if you develop
breathing, swallowing, or speech difficulty.
Too frequent or excessive dosing of Botulinum Toxin may increase the risk of antibodies in the blood
which may lead to failure of treatment with botulinum toxin when used for this and other
conditions. The aesthetic effects of Botulinum Toxin last for an average of 3-4 months but will vary
depending on the condition of the skin, area treated, amount of product injected, injection
technique and lifestyle factors such as sun exposure and smoking.
After treatment, please avoid extreme facial expressions, alcohol consumption and applying make
up for 12 hours. Please avoid sun exposure, UV light, freezing temperatures and saunas for 2 weeks
after treatment.
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PRECARE
(Before treatment)
One week prior to your Botulinum Toxin treatment, we advise you to avoid using alcohol, garlic,
and/or aspirin, or any other non-steroidal anti-inflammatory drugs for pain, swelling and/or fever,
such as medicines containing diclofenac, mefenamic acid, indomethacin or ibuprofen - ask your
doctor or pharmacist whether your medication includes any of these ingredients. Following these
instructions will reduce the risk of bruising or bleeding at the point of injection.
If this is your first visit, you will need to provide your medical doctor with information on your
medical history and any current problems, as well as details of any allergies you have or medications
you are taking. There is no need for an allergy test, unless your medical practitioner feels it’s
necessary.
POSTCARE
(After treatment)
The aesthetic effects of BOTOX® last for an average of 3-4 months but will vary depending on the
condition of the skin, area treated, amount of product injected, injection technique and lifestyle
factors such as sun exposure and smoking. Results of your treatment may take up to 14 days to take
full effect.
After treatment:
• For 4 hours - do not lie down or do “strenuous” exercise and similar activities, nor should
you do anything that increases the blood flow to the injection area
• For 12 hours - avoid extreme facial expressions, alcohol consumption, and applying make-up
• For 24 hours - do not rub or massage the treated areas as this could influence the effect of
the product
• For 2 weeks - avoid direct sun exposure, UV light, freezing temperatures and saunas
Please consult with your medical doctor if further treatment is required.
Treatment may be refused by your HCP if it is not considered in your best interest to proceed.
I understand that I can withdraw this consent at any stage prior to the commencement of treatment,
and that any subsequent decision relating to refusal of continued treatment, including top-ups, will
have an effect on the achievement of the treatment. I therefore consent to receiving the described
treatment by my medical doctor.
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Filler
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I confirm I have been informed that:
The filler is injected into the skin to help correct wrinkles, folds and lines of the face and skin, or for
lip enhancement. You should be aware that the combination of fillers with certain drugs (e.g., beta-
blockers) that reduce or inhibit the metabolism of the liver is inadvisable. Ask your doctor for
guidance. You should be made aware that this product contains 0.3% of lidocaine (lidocaine is a local
anaesthetic, i.e., it alleviates feelings of pain), that may produce a positive result in anti-doping tests.
Due to the use of a needle, there is likely to be some bleeding at the injection site. Reactions giving
rise to, for example, redness and swelling may occur after the injection, and this may be associated
with stinging, itching or discomfort upon pressure at the injection site. This reaction may last for
several days. Rarely discoloration of the injection site, necrosis (tissue death), abscess formation,
granulomas (small bumps), hypersensitivity and hematomas (excessive bruising) have been
reported. Indurations (hardening) or nodules (bumps) may develop at the injection site. Rare but
serious adverse events associated with intravascular injection of dermal fillers in the face and tissue
compression have been reported and include temporary or permanent vision impairment. In
addition, abscesses, granuloma and immediate or delayed hypersensitivity after hyaluronic acid
and/or lidocaine injections have also been reported.
If any of these symptoms persist for more than one week, or if any other side effects develop please
report them to your medical doctor as soon as possible so that they can advise you on the best
course of treatment. Whilst rare, such side-effects and their treatment may last for several months.
The aesthetic effects of dermal filler products can last from 9 to 24 months. The aesthetic effect of a
skin booster skin quality injectable, can last up to 9 months. Results will vary depending on the
condition of the skin, area treated, amount of product injected, injection technique and lifestyle
factors such as sun exposure and smoking.
The average life of treatment in the lips is less than in other areas because of the increased activity
of the lip area. A touch-up procedure may be required 1-3 weeks after the first injection and helps to
optimize the results and maximize the duration of the results.
After treatment, please avoid extreme facial expressions, alcohol consumption and applying make
up for 12 hours. Please avoid extreme sun exposure, UV light, freezing temperatures and saunas for
2 weeks after treatment.
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PRECARE
(Before treatment)
One week prior to your filler injection, we advise you to avoid using alcohol, garlic and/or aspirin, or
any other non-steroidal anti-inflammatory medicines for pain, swelling and/or fever, such as
medicines containing diclofenac, mefenamic acid, indomethacin or ibuprofen - ask your doctor or
pharmacist whether your medication includes any of these ingredients. Following these instructions
will reduce the risk of bruising or bleeding at the point of injection.
If this is your first visit, you will need to provide your medical doctor with information on your
medical history and any current problems, as well as details of any allergies you have or medications
you are taking. There is no need for an allergy test, unless your medical practitioner feels it’s
necessary.
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POSTCARE
(After treatment)
Because the filler injectable gel is a non-surgical treatment, there is minimal recovery time. For the
first 24 hours following treatment, you should avoid strenuous exercise, excessive sun or heat
exposure, and alcoholic beverages, in order to help minimize the risk of temporary redness, swelling
and/ or itching.
No treatment can halt the ageing process; you will require top-ups if you want to maintain the effect
so ask your medical doctor when he/she would recommend rescheduling another appointment.
Treatment may be refused by your HCP if it is not considered in your best interest to proceed.
I understand that I can withdraw this consent at any stage prior to the commencement of treatment,
and that any subsequent decision relating to refusal of continued treatment, including top-ups, will
have an effect on the achievement of the treatment. I therefore consent to receiving the described
treatment by my medical doctor.
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Consent for Treatment with Hyaluronidase
Hyaluronic acid (HA) fillers are sterile gels consisting of non-animal stabilized hyaluronic acid for injection into the skin to correct facial lines, wrinkles and folds, for lip enhancement and for shaping facial contours.
Occasionally these fillers need to be dissolved when the aesthetic treatment has not produced the desired outcome or there is a possibility of vascular occlusion or impending necrosis (tissue death) which could lead to compromise of healthy tissue.
Hyaluronidase is an enzyme which breaks down hyaluronic acid fillers, but it can also break down naturally occurring hyaluronic acid present in the body, the results can be unpredictable.
I understand that there will be loss of volume and there can be some skin laxity which in itself may not provide a good aesthetic result. Although some of the effects can be immediate, I understand it can take up to 24-48 hours for results to be seen and the treatment may need to be repeated.
What are the possible side effects of hyaluronidase?
Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Less serious side effects may include pain, itching, redness, or swelling where the medication was injected. This is not a complete list of side effects and others may occur.
I have disclosed all my medical history and medications to my provider. I am currently not taking any of the following medications. 1) Furosemide (Lasix) 2) Phenytoin (Dilantin) 3) A sedative or anxiety medication (such as Valium, Xanax) 4) Aspirin or salicylates 5) Cortisone or ACTH (Corticotropin) 6) Estrogens 7) An antihistamine (such as a cold or allergy medicine)
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The use of and the indications for the administration of hyaluronidase have been explained to me by my practitioner and I have had the opportunity to have all questions answered to my satisfaction.
After the treatment some other common injection-related reactions might occur. These reaction may include redness, swelling, pain, itching, bruising and tenderness at the injection site. They have generally been described as mild to moderate and typically resolve spontaneously a few days after injection. I acknowledge that I will have to remain at the clinic for thirty minutes after the procedure so that I can be observed by the practitioner and that I may need to return to the clinic in 1-2 weeks after treatment to assess if further hyaluronidase is to be administered. I have answered the questions regarding my medical history to the best of my knowledge.
I have also received the aftercare information and its contents have been explained to me and I will follow the advice given.
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