Dermal Filler Consent
Your clinician wishes to help you make an informed decision about your treatment options and any relevant alternative options. You may at any time decline treatment even after giving your consent.
Whilst your clinician will make every effort to understand what significance you would attach to any particular risk it is important to us that you feel comfortable enough to question the clinician on any point of concern during this process. Please feel you have as much time as you wish to reflect on the information given before agreeing to proceed with the treatment.
You have presented with concerns which have formed the basis of a clinical discussion and examination. The purpose of the proposed treatment is to address your concerns either individually or in combination with other modalities of treatment.
Your clinician will endeavor in good faith to employ the principles of best practice in delivering your treatment. Each patient is individual and response to treatment will vary from patient to patient and treatment to treatment. As such it is difficult to guarantee outcomes will always meet your expectations.
These injectable products are a sterile, pyrogen-free physiological solution of hyaluronic acid of non- animal origin. The products have been extensively tested and found suitable and safe as an injectable implant intended for injection to correct facial and body structural defects such as asymmetry, contour deformities and volume loss in the lips, cheeks, chin and lower face. The range is also suitable for enhancement, fine line treatment. Each product has a different consistency, and your clinician will advise on the appropriate product to be used to give the desired results.
In addition to hyaluronic acid, some syringes contain a small amount of lidocaine hydrochloride and a phosphate buffer. It is important to advise your clinician if you are allergic either to hyaluronic acid or lidocaine.
Paresthesia (nerve problems, loss of sensation, loss of motor function) Itching
Induration or nodules at the injection site Staining or discoloration,
Poor or weak filling effect Infection/abscess formation
Immediate or delayed hypersensitivity reactions to hyaluronic acid or lidocaine
Rare but serious adverse events may be associated with intra vascular injection or tissue compression which have been reported to cause temporary or permanent vision impairment, blindness, cerebral ischemia or cerebral hemorrhage, leading to stroke, skin necrosis and/or damage to underlying structures.
Every care is taken to deliver the products in a manner which will minimize risk, however you should be aware of the risks, as one may exist upon which you place particular significance.
Patients are advised to take in to account all these potential risks before consenting to treatment. Please make your clinician fully aware of your expectations prior to giving consent.
The incidence of allergic reaction has been found to be low and as the products are non-animal based, usually no test patching is required. Should your clinician have concerns about your history of allergies it may be prudent to test a small amount of product before commencing treatment.
Hypersensitivity to lidocaine, other amide-type local anesthetics, or gram-positive bacterial proteins untreated epilepsy
Use with extreme caution in patients who tend to develop hypertrophic scarring If you are, Pregnant or breastfeeding
Limited or no clinical data exists regarding the efficacy and tolerance of this treatment in patients having a history of, or currently suffering from, auto-immune disease or auto-immune deficiency or being under immunosuppressive therapy. The clinician shall therefore decide on the indication on a case by case basis according to the nature of the disease and its treatment and the need for monitoring post-treatment. Your clinician will discuss the need for a preliminary skin testing for hypersensitivity if necessary, or in the case of patients with severe or multiple allergies. Patients on coagulation medication or other substances known to increase coagulation time must be aware of the potential increased risk of bleeding and hematoma during and following treatment.
Your clinician will also discuss the suitability of treatment having considered your medical history and any medications you currently take, as appropriate. As such, it is imperative you disclose such medications at the time of your treatment.
Depending on the specific product used the aesthetic effect can last 6 – 18 months. Please ask your doctor to advise you regarding specific expected longevity for your treatment. Hyaluronic acid is a non-permanent treatment which is fully biocompatible, degradable, and dissolvable. Patients should avoid aspirin and non-steroidal anti-inflammatory medication prior to treatment, where possible to minimize the risk of bruising. Your clinician may wish to defer treatment should you have an active cold sore lesion in the vicinity of proposed treatment.
Most treatments are relatively painless but for more superficial treatment you may require a topical anesthetic to be applied for at least 30 minutes pre-treatment.
Please be aware that if filler needs to be dissolved for any reason, you must wait 2 weeks after being dissolving before attending another filler treatment in that area.
There may be some tenderness, redness and swelling to the site, this is very normal, and this usually subsides within a few days. Bruising is an occasional outcome and generally resolves. It is important to let your clinician know prior to treatment if you have important work or social engagements which may cause you embarrassment should you bruise excessively. It is recommended not to wear make up for to 12 hours post treatment in most cases. It is advisable to avoid extreme temperatures until tenderness and redness subsides. Similarly, strenuous exercise or alcohol would best be avoided for 24 hours. Please ask your clinician for an after-care sheet which will give important contact details and a summary of our advice. Please do not hesitate to contact us should you have any concerns post treatment.
Consent to Treatment
History - Please complete the following questions
Are you currently pregnant or breast feeding trying to conceive or IVF treatment?
Do you suffer from any known allergies to drugs, food, etc?
Have you ever been in hospital with a severe allergic reaction?
Do you take any medication?
Have you taken warfarin, ibuprofen, or aspirin in the last ten days?
Have you taken antibiotics in the last two weeks?
Do you take steroids?
Have you taken Isotretinoin or Roaccutane (for acne) in the past 12 months?
Have you had any facial surgery or significant facial injury?
Do you have any permanent implants in your face?
Do you plan to have any dental treatment in the next 2 weeks?
Have you been treated with either Botulinum Toxin (Botox, Vistabel, Dysport, Azzalure, Xeomin or Bocouture?
Have you had a treatment with a Dermal Filler before?
Have you had any IPL or skin peels in the last six weeks?
Do you currently have COVID-19?
Do you have anxiety or any phobias that may affect treatment? E.g. needles, blood.
Are you prone to fainting, bleeding, bruising, or keloid scaring?
Have you had any sunbed treatment, skin peels, microdermabrasion, or laser in the last 6 weeks?
Do you suffer from any of the following illnesses or diseases? Please tick
Model consent to treatment
I consent to acting as a model for the purpose of training (under supervision) in the administering of Dermal Fillers. The use and indications for the products that I will be treated with have been explained to me by the practitioner and I have had the opportunity to have all my questions answered to my satisfaction. I have answered the questions regarding my medical history to the best of my knowledge.
Training course times may be delayed due to unforeseen circumstances. It may take longer training the students or the student may need more support. So please allow extra time in case this event occurs. Your full payment for your treatment as a model is non-refundable. If the circumstances occur outlined above and/or cancellation your payment is non-refundable. The full payment will be made prior to attending the training academy.
Every procedure involves a certain amount of risk and it is important that you understand the risks involved. An individual’s choice to undergo a procedure is based on the comparison of the risk to potential benefit. Although most patients do not experience these complications, you should discuss each of them with your practitioner to ensure you understand the risks. Potential complications and consequences of - Dermal Fillers – bleeding, bruising, swelling, infection, lumpiness, discoloration, pain or headaches. Muscle weakness near where the medicine was injected. Trouble swallowing for several months after treatment; muscle stiffness, neck pain, pain in your arms or legs; blurred vision, puffy eyelids, dry eyes, drooping eyebrows; dry mouth; headache, tiredness.
I consent to Ampika’s Aesthetics using photographs photographs being stored on a training file and be used for social media purposes photographs and/or video recordings including images of me both internally and externally to promote the Training Academy. These images could be used in print and digital media formats including print publications, websites, e-marketing, posters banners, advertising, film, social media, teaching and research purposes. I understand that images on websites can be viewed throughout the world and not just in the United Kingdom and that some overseas countries may not provide the same level of protection to the rights of individuals as EU/UK legislation provides. I understand that some images or recordings may be kept permanently once they are published. I have read and understand the conditions and consent to my images being used as described.
I am signing to consent to my treatment being administered at Ampika’s Aesthetics. On behalf of the training academy Ampika’s Aesthetics - Ampika’s Hair Make Up and Beauty. You are agreeing to be a model and hold no responsibility towards Ampika’s Aesthetics for any procedures that may incur any personal dissatisfaction or cause of concern.
Any models wishing to seek any legal or liable action will not be permitted to do so once signing this disclaimer you are excepting full responsibility to allow a student to carry out your injectable treatments.
These Students who are responsible for carrying out the treatment under medical supervision, are not fully qualified to carry out Dermal fillers unassisted. Therefore, you understand the risk that this may pose. Any concerns must be addressed whilst you are present in the training academy. Whilst all the trainers accommodate you to ensure you are fully satisfied with your treatment, we are unable to rectify problems weeks after you have undergone the treatment. If there are any concerns then please contact the training academy within 48 hours of treatment.
If you are dissatisfied by your filler application you must email over to [email protected] with your concern. One of the team will get back to you within the working hours on our website. If by personal choose you decide to reverse your application of filler you must email over to [email protected] for one of the team to get back to you on any working day. This will come at a charge of £50 per area. Which will include the medical practitioner to carry out the treatment Dental block and the cost of Hyalase.
By signing this form you have agreed to consent to adhere to our vaccination policy.
I consent I have read and understood the aftercare sheet which has been provided to me
The information that I have given is correct to the best of my knowledge.
I have not knowingly withheld any medical information.
I consent to the treatment described.
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Your legal name
Your email address
Signed by Ampika Pickston
Signed On: June 9, 2021
If you have questions about the contents of this document, you can email the document owner.
Document Name: Dermal Filler Consent
Agree & Sign