Dermal Fillers | TOA CLINIC
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Dermal Fillers 
Consent Form
 

Please fill out the following form
in order to participate in our activity.

Are you currently in good health?
cardiac pacemakers, implanted defibrillators, implanted neurostimulators
drug pumps
Do you carry a warning card, an EpiPen, or have you ever had an anaphylaxis reaction?
malignant tumor
Fever
sensitivity or allergy to latex
haemorrhagic conditions
anticoagulation therapy
heart disorders
epilepsy
Are you currently under a specialist, hospital or doctor’s care
areas of the skin which lack normal sensation
Do you use ANY medication, herbal/natural supplements or topical creams on a regular basis
Do you have ANY allergies to medications, food, latex, or other substances
Have you had any cold sore breakouts (oral herpes) in the past year
Do you have a history of Keloid Scarring
Any blood-borne diseases
A stroke or any other blood pressure problems
Any neurological conditions such as epilepsy, Bell’s Palsy, MS, Chorea or Myasthenia Gravis
Allergic to latex, antibiotics, foods, drugs/substances
Any recent vaccinations, cortisone injections or steroids
Replacements, implants, operations, X-rays recently
Do you suffer with Acne, or have you taken medication for Acne in the past 6 months
Do you have ANY current or chronic medical illness, including: Myasthenia Gravis, Amyotrophic Lateral Sclerosis or any other Neuromuscular disorders
Do you have an autoimmune disease
Jaundice, Hepatitis, Liver or Kidney disease
Have you ever had eyelid or facial surgery
Asthma, Eczema or other allergic disease
AIDS/HIV
Deep skin peeling
Have you previously received BOTOX/ DERMAL FILLER injections
Are you, or could you be pregnant
Are you going through IVF
Are you breastfeeding
Taking medicines, pills, tablets, ointments or inhalers
Use therapies or supplements such as St. John’s Wort?
Do you bruise or bleed easily
Any circulative problems or varicose veins
Any auto-immune disease, including lupus
Any endocrine disorders? (diabetes, thyroid)
Do you follow a healthy diet?
Bleeding and Bruising: It is possible, though unusual, to have a bleeding episode from a Dermal Fillers injection during the procedure. Bruising in soft tissues may occur. Should you develop post-injection bleeding, it may require emergency treatment or surgery. Aspirin, anti-inflammatory medications, platelet inhibitors, anticoagulants, Vitamin E, ginkgo biloba and other “herbs / homeopathic remedies” may contribute to a greater risk of a bleeding problem. It is recommended not to take any of these for seven days before or after Dermal Fillers injections. Swelling: Swelling (edema) is a normal occurrence following the injections. It decreases after a few days. If swelling is slow to resolve, medical treatment may be necessary. Erythema (Skin Redness): Erythema in the skin occurs after injections. It can be present for a few days after the procedure. Needle Marks: Visible needle marks from the injections occur normally and resolve in a few days. Acne-Like Skin Eruptions: Acneiform skin eruptions can occur following the injection of tissue fillers. This generally resolves within a few days.
Skin Lumpiness: Lumpiness can occur following the injection of Dermal Fillers. This tends to smooth out over time. In some situations, it may be possible to feel the injected tissue filler material for long periods of time. Visible Tissue Filler Material: It may be possible to see any type of tissue filler material that was injected in areas where the skin is thin. Asymmetry: The human face is normally asymmetrical in its appearance and anatomy. It may not be possible to achieve or maintain exact symmetry with tissue filler injections. There can be a variation from one side to the other in terms of the response to Dermal Fillers injection. This may require additional injections. Pain: Discomfort associated with Dermal Fillers injections is normal and usually of short duration. Skin Sensitivity: Skin rash, itching, tenderness and swelling may occur following Dermal Fillers injections. After treatment, you should minimize exposure of the treated area to excessive sun or UV lamp exposure and extreme cold weather until any initial swelling or redness has gone away. If you are considering laser treatment, chemical skin peeling or any other procedure based on a skin response after Dermal Fillers treatment, or you have recently had such treatments and the skin has not healed completely, there is a possible risk of an inflammatory reaction at the implant site.
RISKS OF DERMAL FILLERS INJECTIONS Damage to Deeper Structures: Deeper structures such as nerves and blood vessels may be damaged Infection: Although infection following injection of tissue fillers is extremely rare, bacterial, fungal, and viral infections can occur, if you already have the infection or a history of the infection. Herpes simplex virus infections around the mouth can occur following a tissue filler treatment. This applies to both individuals with a past history of Herpes simplex virus infections and individuals with no known history of Herpes simplex virus infections in the mouth area. Specific medications must be prescribed and taken both prior to and following the treatment procedure in order to suppress an infection from this virus. Should any type of skin infection occur, additional treatment including antibiotics may be necessary. Skin Necrosis: Although rare it is very unusual to experience death of skin and deeper soft tissues after Dermal Fillers injections. Skin necrosis can produce unacceptable scarring. Allergic Reactions and Hypersensitivity: As with all biologic products, allergic and systemic anaphylactic reactions may occur. Dermal Fillers should not be used in clients with a history of multiple severe allergies, severe allergies manifested by a history of anaphylaxis, or allergies to gram-positive bacterial proteins. Allergic reactions may require additional treatment. Scarring: Dermal Fillers should not be used in clients with known susceptibility to keloid formation or hypertrophic scarring. The safety of clients has not been studied.
Granulomas: Although rare painful masses in the skin and deeper tissues after a Dermal Fillers injection can occur. Skin Disorders: Dermal Fillers should not be used in areas with active inflammation or infections (e.g. cysts, pimples, rashes or hives). In rare instances, granuloma or abscess formation, localized necrosis and urticaria have been reported. Antibodies to Dermal Fillers: Presence of antibodies to hyaluronic acid tissue fillers may reduce the effectiveness of this material or produce a reaction in subsequent injections. The health significance of antibodies to hyaluronic acid tissue fillers is unknown. Accidental Intra-Arterial Injection: It is extremely rare that during the course of injection, Dermal Fillers could be accidentally injected into arterial structures and produce a blockage of blood flow. This may produce skin necrosis in facial structures or damage blood flow to the eye, resulting in loss of vision. The risk and consequences of accidental intravascular injection of Dermal Fillers is unknown and not predictable.
Unknown Risks: The long-term effect of Dermal Fillers beyond one year is unknown. The possibility of additional risk factors or complications attributable to the use of Dermal Fillers as a soft tissue filler may be discovered. Drug Interactions: It is not known if Dermal Fillers reacts with other drugs within the body. Long-Term Effects: Dermal Fillers injections should not be considered as a permanent treatment for the correction of wrinkles and soft tissue depressions. Over time, the Dermal Fillers material is slowly absorbed by the body and wrinkles or soft tissue depressions will reappear. Continuing Dermal Fillers treatment (injections) is necessary to maintain the effect of Dermal Fillers. Subsequent alterations in face and eyelid appearance may occur as the result of ageing, weight loss or gain, sun exposure, or other circumstances not related to Dermal Fillers injections. Future surgery or other treatments may be necessary. Dermal Fillers injection does not arrest the ageing process or produce permanent tightening of the skin or improvement in wrinkles. By signing below I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent dermal filler treatments with the above understood. I hereby release the person injecting the dermal filler, supervisors, and the facility (TOA Clinic) from liability associated with this procedure.
DERMAL FILLER RESULTS I am aware that full correction is important and that follow-up enhancement treatments will be needed to maintain the full effects.  I am aware that the duration of treatment is dependent on many factors including but not limited to: age, sex, tissue conditions, my general health and lifestyle conditions, and sun exposure.  The correction, depending on these factors many last 6-12 months and in some cases shorter and some cases longer. I have been instructed in and understand post-treatment instructions and have been given a copy of them. I hereby voluntarily consent to treatment.  The procedure(s) has been explained to me. I have read the above and understand it.   My questions have been answered satisfactorily. I accept the risks and complication of the procedure.  I certify that if I have any changes occur in my medical history, I will notify aUK. I have read this informed consent and certify that I understand its contents in full. I have had enough time to consider the information from my practitioner and feel that I am sufficiently advised to consent to this procedure. I hereby give my consent to this procedure and have been asked to sign this form after my discussion with the practitioner.
Is there anyone that cannot be treated? Dermal Fillers should not be used in clients who have severe allergies marked by a history of anaphylaxis, a history of severe allergies, or clients with a history of a compromised immune system. Pregnant or breastfeeding mothers are also exempt. The practitioner will ask you about your medical history to determine if you are an appropriate candidate for treatment. What should I expect with HA dermal filler treatments? The practitioner will go over a list of pre and post treatment procedures with you. If you are taking Aspirin or Ibuprofen you may experience increased bruising or bleeding at the injection site. HA dermal fillers should be used with caution in clients on immunosuppressive therapy as there may be an increased risk of infection, swelling and adverse events.
Procedure This product is administered via a syringe, or injection, into the areas of the face sought to be filled with the hyaluronic acid to eliminate or reduce the wrinkles and folds. An anaesthetic, numbing medicine used to reduce the discomfort of the injection, may or may not be used. The treatment site(s) is washed first with and antiseptic (cleansing) solution. Dermal fillers are clear transparent gels that is injected under your skin into the tissue of your face using a thin gauge needle. The depth of the injection(s) will depend on the depth of the wrinkle(s) and its location(s) Multiple injections might be made depending on the site, depth of the wrinkle, and technique used. Following each injection, the injector should gently massage the correction site to conform to the contour of the surrounding tissues. If the treated area is swollen directly after the injection, ice may be applied on the site for a short period. After the first treatment, additional treatments of dermal fillers may be necessary to achieve the desired level of correction. Periodic enhancement injections help sustain the desired level of correction.
What are post treatment/aftercare procedures? For the first 24 hours following treatment, you should avoid strenuous exercise, excessive sun or heat, and consumption of alcoholic beverages. This minimises the risk of temporary redness, swelling, and/or itching at the treatment sites. These temporary side effects generally resolve themselves within one week. An ice pack can be applied to the site if you experience swelling. You may apply makeup as usual after 24 hours.

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