Skin Booster Consent
Important Background to the Consent Process
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.
Purpose of 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.
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.
Contraindications and Relative Contraindications to 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
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.
Do you have any history of anaphylactic reaction?
Do you have a known sensitivity to Lidocaine (numbing agent commonly used by dentists or doctors)?
Do you have a known hypersensitivity (allergy) to hyaluronic acid or any other injectable dermo aesthetic product?
Is there any possibility of pregnancy or are you breastfeeding?
Have you suffered from herpes simplex (cold sores) within the last 2 weeks?
I have been told that reactions such as redness, oedema, pain and itching may follow treatment, as may an acne like eruption. All these reactions are linked to the procedure itself and usually resolve after few days. I was also informed about very rare cases, as described in literature, of discoloration at the injection point, necrosis of glabellar area, vascular occlusion , intraocular complications and hypersensitivity after hyaluronic acid injections. All side effects must be reported to the practitioner as soon as possible. Patients who have had herpes simplex (cold sores) in the past should note that there is always a risk that injecting any product around lip area and / or previously affected areas may cause the herpes to flare up again.
I understand that the result of the treatment is variable, and that the outcome of the treatment cannot be guaranteed. After treatment, I will follow the advice given by my practitioner to achieve satisfactory aesthetic results. I realise that if I do not follow this advice, the end result may be less optimal. I am aware of the importance of follow-up care and my own responsibility.
How and when IBSA's products should be used, treatment procedure, limitations, the applicable contraindications and possible undesirable effects have been explained to me. I have replied in all honesty to all questions about my medical and aesthetic history. I have been given the chance to ask all the questions I wanted and I have received satisfactory replies to all of them. Now that the procedure has been fully explained to me, I consent to have the injectable treatment.
I consent to acting as a model for the purpose of training (under supervision). 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.
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 Skin Boosters 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.
I consent to Ampika’s Aesthetics using 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.
If you are dissatisfied by your treatment 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.
By signing this form you have agreed to consent to adhere to our vaccination policy.
I consent I have read and understood the after-care 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
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Signed by Ampika Pickston
Signed On: March 24, 2021
If you have questions about the contents of this document, you can email the document owner.
Document Name: Skin Booster Consent
Agree & Sign