Section 1 - Personal Details
Are you currently:
Section 2 - Medical History
Section 3 - Current Medical Status
Section 4 - Dermal Fillers Overview
General information: The next several sections have been prepared to ensure informed consent and help you in relation to understanding your Dermal Fillers injections with a general overview, need to know information, risks and alternative treatments.
Dermal Fillers are a multi-functioning treatment and can be used to reduce deep lines and wrinkles, fill hollows and smooth contours as well as adding or restoring volume to areas of the face such as the lips or cheeks.
At around the age of 25 the body stops producing collagen and elastin, the two proteins that work together to keep tissue firm and skin elastic, and the existing collagen in the body begins to break down. Without these two proteins, the body begins to display the typical signs of aging (things like sunken cheeks, hollow eyes, deep lines and wrinkles) as the body no longer has a means of keeping tissue strong and skin supple.
Anti-ageing facial fillers are a non-surgical solution to achieve younger looking skin as well as smooth out tired lines and wrinkles, providing natural looking rejuvenated outcomes.Hyaluronic Dermal Fillers Overview:
Hyaluronic Acid is a naturally occurring sugar chain molecule found in all skin and soft tissue throughout the body, identical across species. It attracts and binds water in the skin, providing volume and hydration but also 'cushioning' and supporting collagen and elastin fibres and providing a carrier, for chemical messages between the cells.
Dermal Fillers are manufactured, usually through fermentation and cross linking with proteins to produce a clear, sterile gel for injection into the skin, providing instant correction. In the UK there are over 160 brands on the market, due in some part to weak regulation.
Not all Hyaluronic Acids are the same and legitimate brands are NOT available for general sale on the internet and should only be administered by trained clinicians. Each brand has a range of 'tissue tailored' products designed for specific results. One size does not fit all.
Leading and well established brands include, but are not limited to:
Juvederm™ (FDA 2006)
Restylane™ (FDA 2003)
Belotero™ (FDA 2011)
Teosyal™
Emervel™
The treatment you, the client are going to receive utilises Dermal Fillers consisting of Hyaluronic Acid, which depending on the procedure agreed upon, will be injected into areas of the face and upper body for the correction of facial lines, wrinkles, folds, lip enhancement and the shaping of facial contours.
The Dermal Filler used is in line with current UK safety standards. It is a non-permanent procedure, and a repeat procedure may be required to maintain results.
Section 5 - Alternative Treatment Options Alternatives Although Dermal Filler are a highly effective wrinkle and volume management treatment there are alternatives that clients may wish to consider. An alternative to Dermal Fillers are surgery options targeted toward restoring a more youthful looking appearance such as blepharoplasty (treatment to the eye-region), brow or face lifts.
Moreover minor skin wrinkles may not need such extreme treatment options to manage, their appearance may be improved through the use of chemical skin peels, laser treatments, injection of filling / plumping materials, natural facials, among other skin treatments.
Be aware that each form of treatment is not without its risks and considerations, individuals looking to seek alternative treatments should always research and discuss with a professional the considerations they will need to take prior to giving informed consent for any treatment they choose to pursue.
Please note an alternative form of management is also to not treat the skin wrinkles, there is no one treatment that can prevent or stop the skins natural ageing process.
Section 6: Treatment Risks Treatment risks No matter the treatment option you choose to pursue, no treatment is without risk or possible complications, Dermal Filler treatments included. It is up to the patient to weigh the risk with the possible outcome, although the majority of individuals treated do not experience these complications we urge you to carefully read the following possible risks and complications, then further discuss anything you are not sure on with your aesthetician, to ensure you can make a fully informed decision.
Pain - Dermal Filler Treatments are not without a slight level of discomfort, this can be compared to any needle type treatment, and is usually only experienced for a short duration.
Asymmetry - With regards to human anatomy and structure, the face regions are naturally asymmetrical, as such variation in response to Dermal Filler injections from one side of the face to the other is common.
Migration of Dermal Fillers - It is possible for Dermal Fillers to migrate from the original injection site to the surrounding areas, volume of unintended areas.
Damage to Deeper Structures - Deeper structures i.e. nerves, blood vessels, and the eyeball can potentially be damaged during the injection process. Injury to deeper structures can be temporary or permanent.
Infections - Infection following filler injections is extremely rare, however if you do experience an infection please consider seeking medical advice and addition treatment i.e. antibiotics.
Bleeding and Bruising - Although unusual there is a potential to experience a bleeding episode during or following Dermal Filler injections; bruising in soft tissues can occur. Should you begin to develop post-injection bleeding please consider seeking medical advice as this may require emergency treatment or surgery. Certain substances may cause you to be at greater risk to experience bleeding, these include aspirin, anti-inflammatory medications, platelet inhibitors, anticoagulants, vitamin E, ginkgo bilboa, and other 'herbs / homeopathic remedies', if you take any of these substances please refrain from doing so 10 days prior and following your Dermal Filler Treatments.
Antibodies to Dermal Fillers - The presence of antibodies to Dermal Fillers may reduce the effectiveness of the material in treatments following your initial experience with Dermal Fillers, please be aware the health significance of antibodies to Dermal Fillers is currently unknown.
Allergic Reactions - As with all biologically occurring products allergic and systemic anaphylactic reactions may occur. If you experience allergic reactions or reaction type symptoms following a Dermal Filler treatment please consider seeking medical advice as this may require medical intervention.
Localised Reaction - A small number of individuals can experience a rarer form of localised reaction, these are thought to be due to hypersensitivity. These forms of reaction usually consist of swelling at the injection site which can also affect surrounding tissues; redness, tenderness and more rarely acne-like formations can also be experienced. This type of reaction starts a few days following treatment or after a longer delay of 2 - 4 weeks. Please view the manufacturers information on side effects for further information.
Blindness - Blindness is an extremely rare complication to experience following Dermal Filler injections, however it can be caused by internal bleeding around the eyeball or needle stick injury. The occurrence of eye problems is considered very rare, with only 3 confirmed reported instances of complications with blurred vision, retinal vein occlusion and glaucoma having been reported in a period of 10 years of Dermal Filler aesthetic treatment. If you believe you are experiencing blindness due to Dermal Filler treatment please seek urgent immediate medical advice.
Pregnancy and Nursing Mothers - As there has been no studies performed to determine if Dermal Fillers can cause fatal harm it is not recommended for pregnant women to receive Dermal Filler treatments. It is also not known if Dermal Fillers can be excreted in human milk, a such if you are a nursing Mother it is not recommended you receive Dermal Filler treatments.
Long-term Effects - Alterations to the appearance of the face and eyelid will occur over time, this can be the result of ageing, weight loss / gain, sun exposure, pregnancy, menopause, or other circumstance unrelated to Dermal Filler treatment. Dermal Filler treatments do not stop or prevent the ageing process, or produce a permanent tightening of the chosen treatment area. If this the desired result you may wish to seek further treatment i.e. surgery for a permanent result.
Unsatisfactory Results - If you experience an inadequate initial response to Filler injections please be aware additional injections may be necessary to achieve your desired result, please discuss any unsatisfactory results further with your aesthetician.
Unknown Risks - Currently the long-term side effects of Dermal Fillers on tissue is not known. Risks and consequences of accidental intravascular injection of Dermal Fillers is currently unknown and unpredictable. It is still possible for the additional risk factor to be discovered in future.
Section 7: General Risks
General risks Bleeding - It is possible, although unusual, to experience a bleeding episode during or following your injections, should bleeding occur it may require emergency treatment to drain the accumulated blood or you may require a blood transfusion, however such occurrences are rare. Increased activity too soon after surgery can lead to increased chance of bleeding and requirement of additional treatment. It is important to follow your treatment-aftercare advice and limit exercise and strenuous activity for the advised time. Do not take any aspirin or anti-inflammatory medications for at least 10 days before or after treatment, as these substances can lead to an increased risk of bleeding; other non-prescription ‘herbs and homeopathic substances’ or dietary supplements can increase the risk of bleeding. Hematoma can occur at any time usually within the first 3 weeks following injury to the area, it may take 1 - 4 weeks depending on the size of the hematoma for it to dissolve and be absorbed. If blood transfusions are necessary to treat blood loss there is a risk of blood-related infections, if you are concerned about any risks relating to a transfusion please seek medical advice from the medical practitioner handling your treatment.
Infection - Infection following Dermal Filler treatments is unusual. Should an infection occur you may require additional treatment such as antibiotics, hospitalisation, or additional surgery may be necessary. It is important to tell your aesthetician of any other infections you’re are currently experiencing i.e. ingrown toenail, insect bite, or urinary tract infection, as remote infections in other parts of your body can lead to an infection of the treated area.
Section 8: Additional Advisories additional advisories Additional advisories
Female Patient Advisory - If your are currently using birth control medications, estrogen replacement, or suspect you may be pregnant it is important you inform your aesthetician; many medications including antibiotics have the potential to neutralise the effect of birth control substances which increases your risk of conception and pregnancy.
Mental Health Disorders and Elective Treatments - It is important all individuals seeking to undergo treatment have realistic expectations that focus on the improvement of intended treatment areas but not perfection. Complications or less than satisfactory results are sometimes unavoidable and may require additional treatments or alternative medical intervention which can cause increased stress for the patient. Prior to treatment please discuss, as openly as possible, any history that you may have of significant emotional depression or mental health disorders. Although many individuals may benefit psychologically and emotionally from the results of treatments, the effects of mental health cannot be predicted.
Sun Exposure (direct or through tanning salons) - The effects of long-term exposure to the sun or through UV lamps is damaging to the skin. Exposing your treated areas to the sun may result in increased scarring, colour changes, or poor healing. Patients who tan, whether outdoors or through the use of salons should inform the aesthetician so a decision for the delaying of treatment or the avoidance of tanning for an agreed period of time can be reached. Please note that the damaging effects from sun exposure, although somewhat limited, will still occur even with the use of sunblock or clothing coverage.
Medication and Herbal Dietary Supplements - There are potential adverse reactions that occur as the result of taking over-the-counter, herbal, and/or prescription medications. Aspirin and medications that contain aspirin interfere with clotting and can cause increased risk of bleeding. These include non-steroidal anti-inflammatories such as Motrin, Advil and Alleve. It is very important that you do not consider stopping the consumption of any drugs that interfere with platelets such as Plavix, which is used after a stent. It is important if you have had a stent and are taking Plavix that you inform the aesthetician. Stopping Plavix may result in a heart attack, stroke or even death. Be sure to check with you medical physician about any drugs and immediately contact your aesthetician for further instructions. If you do experience a reaction contact a medical professional for advice or if you consider it to be severe, go immediately to your nearest emergency room.
Travel Plans - Any treatment holds a risk of complications that may delay healing and delay your return to normal life. Please let the aesthetician know of any travel plans, important commitments already scheduled or planned / time demands that are important to you so that appropriate timing of treatments can be agreed. There is no guarantee that you will be able to resume all activities in the desired time-frame.
‘Off-Label’ Concerns - There many devices, medications, inject-able fillers and Botulinum Toxins that are approved for specific use by the MHRA, but this proposed use is ‘Off-Label’, that is not specifically approved by the MHRA. It is important that you understand the proposed use is not experimental and your aesthetician believes it to be safe and effective. Examples of commonly accepted ‘Off-Label’ use of drugs or devices include the use of aspirin for prevention of heart disease, retinoids for skin care, and injection of Botulinum Toxin for wrinkles around the eye. Botox / Vistabel is approved for Glabellar frown lines, Blepharospasm, and would be ‘Off-Label’ for all other uses.
I, the client, acknowledge that I have been informed about the Off-Label MHRA status for Botulinum Toxin for wrinkle treatments, and I understand this is not experimental and accept its use.
Section 9: Additional Treatment Necessary Additional treatment
There are many variable conditions in addition to stated risk and potential complications which may have an influence on the long-term results of Dermal Filler Injections. Even though complications and risks occur infrequently, the risks cited are those that are particularly associated with Dermal Filler Injections.
Other complications and risks can occur but are more uncommon than those previously cited. Should complications occur, additional treatment may be necessary. The practice of medical or aesthetic treatments is not an exact science, although good results are always expected, there is no guarantee or warranty, express or implied, on the results that may be obtained.
Section 10: Financial Responsibilities Cost responsibility
The cost of Dermal Filler Injections may involve several charges to achieve your desired look. This can include the professional fee for the injections, follow-up visits to monitor the effectiveness of the treatments, and the cost of the Dermal Filler material itself. Additional costs accrued should complications develop from the injections will also be your responsibility, outside of decisions resulting in follow-up injections should you and your aesthetician decide that the complications can be negated or reversed through the use of further treatments.
In signing you agree In signing the consent for this treatment, you acknowledge that you have been informed about its risks and consequences and accept full responsibility for the clinical-cosmetic decisions that were made along with any and all financial costs of current and future treatments.
I, the client, have read, understood and irrevocably accept this.
Section 11: Pre-Treatment Advice Advice
Numbing Cream - YOU ARE LEGALLY REQUIRED TO PURCHASE THIS YOURSELF. IF YOU DO NOT BUY ANY YOU WILL NOT BE NUMBED PRIOR TO TREATMENT. You can buy great numbing creams in pharmacy’s such as Boots or Lloyds, failing this you can buy it online easily. I recommend LMX4 or Emla. Explain to the pharmacist that you having an injection and are worried about needles. Apply this cream to the area liberally about 30 minutes before your treatment. This gives it plenty of time to begin working. The majority of dermal fillers I use have lidocaine inside them too so you will also be numbed from the inside as soon as we begin injecting. If you are unsure exactly where to apply your cream then please message me.
Paracetamol - Please take paracetamol 1 hour before your treatment.
Medical Consent Form - Please do not forget to complete your medical consent form prior to your treatment. YOU CANNOT BE TREATED UNLESS THIS IS COMPLETE.
Pre-treatment Tips:
In order to reduce the amount of bruising and/or swelling from the injection sites, please follow the instructions below.
In order to reduce the amount of bruising and/or swelling from the injection sites, please follow the instructions below.
Avoid blood thinning over-the-counter medications such as Aspirin, Motrin, Ibuprofen, and Aleve for 1 week prior. Please consult your physician if you are taking Aspirin for medical reasons!
Avoid supplements including St. Johns Wort, ginko biloba, primrose oil, garlic, ginseng, and Vitamin E for 1 week.
Avoid topical products such as Tretinoin (Retin-A), Retinols, Retinoids, Glycolic Acid, or any "Anti-Ageing" products for 3 days prior.
Avoid waxing, bleaching, tweezing, or hair removal cream on the area to be treated for 3 days prior.
Do not drink alcoholic beverages for 24 hours prior to treatment.
If you have previously suffered from facial cold sores, there is a risk that the needle punctures could contribute to another eruption of cold sores.
Do not use dermal fillers if you are pregnant or breastfeeding, are allergic to any ingredients, or suffer from neurological disorders. Please inform us if you have any questions.
If you have any questions regarding any of the Pre-Treatment advice please kindly send us an email or message us on social media and we will gladly answer any questions.
Section 12: Salon Terms and Conditions Salon Terms and Conditions Part A - Appointments:
If you are more than 10 minutes late your appointment will need to be rescheduled. Late arrival will result in your treatment being cancelled and 100% charge take.
Part B - Cancellations:
To cancel or change an appointment, a minimum of 72 hours notice is required; otherwise a 100% charge of treatment will be implemented.
Part C - Children:
To respect the relaxing environment we wish to create, as well as to comply with current health and safety regulations, we request that children and babies are not brought into the salon.
Part D - Booking Fees:
A booking fee is taken for every treatment booked, this is to secure the time slot. Booking fees are strictly non-refundable, however can be moved to another date, providing we are notified 72 hours prior to the treatment. Within 72 hours the treatment will be charged at full price. Booking fees can only be moved once. The date to which it is transferred must be within 3 months of the initial booking.
Part E - Prices:
Please note, our prices are subject to change without notice.
Part F - Patch Tests:
Patch Tests are required for every permanent make up treatment at least 24 hours prior to treatment. If you are unable to come into the salon to have a patch test one can be arranged by post.
(THIS WILL NOT BE ARRANGED IF YOU LIVE IN THE TOWN OR SURROUNDING VILLAGES-you must come in and pick your test up, the hairdressers work late so the salon has flexible hours to suit everyone).
Two weeks notice will be required to ensure postal delivery in time. Failure to patch test will result in the treatment being cancelled and potentially charged. Please contact us to arrange your patch test.
Please sign below Please sign below to indicate you have read, understood and agree to all of the above terms
Section 13: Disclaimer Disclaimer information Informed consent documents are used to communicate information about the proposed clinical-cosmetic treatment of a concern or condition along with the disclosure of risks and alternative forms of treatments(s), including but not limited to surgical intervention. The informed consent process attempts to define principles of disclosure that should generally meet the needs of most patients in most circumstances.
However, informed consent documents should not be considered all-inclusive in defining other methods of care and risks encountered. Your aesthetician may provide you with additional or different information which is based on all the facts in your particular case and the current state of medicinal knowledge.
Informed consent documents are not intended to define or serve as the standard of medical or clinical-cosmetic care. Standards of medical and / or clinical-cosmetic care are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve.
It is important that you read the above information carefully and have all of your questions answered before signing the consent at the end of this document.
Section 14: Consent for Procedure and Treatment Informed consent terms This section has been prepared to ensure informed consent and to help you in relation to your Dermal Fillers injections about general information, need to know information, risks and alternative treatments.
A. I hereby authorise the aesthetic practitioners of The JMK Clinic to perform the following procedure or treatment: Dermal Filler Injections.
B. I recognise that during the course of the procedure, unforeseen conditions may necessitate different procedure than those listed above. I therefore authorise the above aesthetician and assistants to perform such other procedure that is deemed necessary and desirable in her informed professional judgement. The authority granted under this paragraph shall include all conditions that require treatment and are not known to my aesthetician at the time the procedure is begun.
C. I understand what my aesthetician can and cannot do, and I understand there are no warranties or guarantees, implied or specific about my outcome. I have had the opportunity to explain my goals and understand which desired outcomes are realistic and which are not. All of my questions have been answered, and I understand the inherent (specific) risks associated with the procedures I seek. As well as those additional risks, complications, benefits and alternatives. Understanding all of this, I elect to proceed with the stated treatment(s).
D. I consent to be photographed, or video-recorded, before, during and following my treatment(s), including appropriate portions of my body for medical, scientific, or educational purposes.
E. I understand that the aestheticians fees are agreeable to me. I understand that if a secondary procedure is necessary, further expenditure will be required.
F. I realise and understand that not having the procedure is an option.
G. I understand that no refunds are given
H. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
THE ABOVE TREATMENT / PROCEDURE TO BE UNDERTAKEN
THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT
THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED.
If receiving a hyaluronidiase treatment (removal of dermal fillers) I consent to the product being used 'off licence'. Off licence does not mean illegally, it means not being used for the intended use approved by MRHA, however MRHA have authorised the product to be safely be used in a way to benefit the client.
I CONSENT TO THE TREATMENT AND THE ABOVE LISTED ITEMS . I AM SATISFIED WITH THE EXPLANATION I HAVE READ / RECEIVED.
Final Form Consent It is important that you read the above information carefully and have any questions answered prior to clicking the final consent.
You agree that you have answered all questions truthfully and disclosed any other relevant information. Failure to disclose correct information can be considered an offence in court
Please check the box to signify you have read and understood this document and consent to the procedure you are about to receive.
I have read and understand this document and consent to the procedure I am about to receive
Submit
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