skincare consent waiver online

Dermal Fillers consent form

Please fill your name: *

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Date of Birth: *

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Please fill in Address (including postcode): *

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Phone number: * Please enter your phone number.

Medications: * Please enter your answer here.

Allergies: * Please enter your answer here.

Is there any chance you could be pregnant and/or breastfeeding? * Please enter your answer here.

Are you taking any medications that may cause your blood to thin? (Etc warfarin, aspirin, apixaban) * Please enter your answer here.

Are you currently undergoing any dental treatment? * Please enter your answer here.

Have you ever had a severe anaphylactic reaction? * Please enter your answer here.

Do you suffer from hypertrophic or keloid scarring? * Please enter your answer here.

Do you have any bleeding/bruising disorders? * Please enter your answer here.

Have you ever had facial surgery? * Please enter your answer here.

Do you suffer with herpes? * Please enter your answer here.

Have you ever had any previous skin peels, laser treatment or injections? * Please enter your answer here.

Have you ever had any previous dermal filler treatment? * Please enter your answer here.

Do you suffer from any skin conditions and/or skin infections? * Please enter your answer here.

Do you have a family history of auto-immune disease? * Please enter your answer here.

Do you suffer from any other medical conditions? * Please enter your answer here.

Please ensure you answer all of the questions above as this may cause a delay in your treatment. For any questions answered yes please give relevant details: * Please enter your answer here.

INFORMED CONSENT - DERMAL FILLERS

I confirm that I consent to receiving treatment using hyaluronic acid filler.
I have been given sufficient information to enable me to understand the product, procedure, risks and side effects.
I understand there is a risk of possible: Bruising, bleeding, redness, swelling, lumpiness, reactivation of herpes, pain & discomfort.
I understand the possible risks with all injectable treatment including: risk of infection, severe bleeding, vessel occlusion with potential lip necrosis, granuloma, haematoma, abscess formation and hypertensive or an allergic reaction.
I agree to the use of a topical anaesthetic cream.
I agree to the post treatment advice given by my practitioner.
I understand that the practice of medicine and surgery is not an exact science and therefore no guarantee can be given as to the results of the treatment referred to in this document. I accept and understand the goal of this treatment is improvement, not perfection, and there is no guarantee that the anticipated results will be achieved.
I understand no procedure is risk free.
I have had the procedure, risks, possible side effects explained to me.
I have had the chance to ask my practitioner any questions.
I understand fillers can have rare, but serious complications that may require an opinion of a plastic surgeon for which PS Beauty & Aesthetics will not be liable for.
I consent I have provided honest and truthful information to my practitioner.
I understand the treatment is non-refundable.
I consent for the use of photography and accept my photos may be used for Be You Aesthetics Leeds marketing and social media
I am aware of the PS Beauty & Aesthetics Privacy Policy and understand that personal information may be passed onto a third party when necessary.

I understand this procedure and I hereby consent to treatment with dermal fillers. The procedure has been fully explained to me and I understand in the rare event of a serious complication I will be liable to seek professional opinion of a plastic surgeon which will not be covered by PS beauty & Aesthetics.

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Date: *

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Today you were treated with Teoxane/Teosyal Hyaluronic Acid Dermal Fillers

If the area becomes extremely painful, white/grey or dusky contact me immediately on: 07341557682

You may have bruising and the area will also swell. Lips can swell up to 30%. The area takes two weeks to fully heal. If there are any lumps or bumps after this duration you can firmly massage.

Use a cold compress and antihistamine to reduce the swelling.

Avoid smoking, alcohol, vigorous exercise and keep the area clean (no makeup) for atleast 24 hours.

Avoid sunbed use for 2 weeks post treatment (Please be aware sunbeds/sun exposure speed up the breakdown of any Dermal Fillers.)

Lips only: Lips can be reinjected after 3 weeks if you wish to build on size. Otherwise once your desired size is achieved we recommend top ups of half a ml every 3-4months.

Feedback and reviews are always much appreciated, please follow me on social media @PSaestheticsx

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