PATIENT CONSENT FOR TREATMENT WITH RESTYLANE® PRODUCTS

Restylane products are sterile gels that consist of cross-linked non-animal based hyaluronic acid. Restylane lidocaine products contain in addition 0.3% lidocaine (a local anaesthetic agent. The products are injected into the skin to correct lines, wrinkles and folds in faces, to sculpt lips and enhance facial contours. They are also used to restore elasticity of skin and reduce irregularities on the skin's surface.

My treating practitioner has explained how and when Restylane products are used. I have been given the opportunity to ask questions and have received satisfactory answers to my questions. In particular, I have received information regarding when treatment with Restylane products should not take place and have also been informed of precautions, warnings for use with these products and common injection- related reactions. These reactions include redness, swelling, pain, itching, bruising and tenderness at the implant location. These reactions are generally mild to moderate and usually disappear shortly after injection. They usually resolve spontaneously a few days after injection into the skin, within a week after injection into the lips.

Yes

I have also been informed of the risks involved when injecting areas with underlying sensitive structures (e.g. nerves, vessels and eyes when treating wrinkles around eyes.

Yes

I have been informed that Restylane products containing lidocaine must not be used in individuals with known hypersensitivity to lidocaine or amide-type local anaesthetics. Similar to administration of dental anaesthetic, there is diminished sensation to pain and temperature in the treated area for about two hours.

Yes

My practitioner has also informed me that topical anesthetic cream might be used to have additional pain relief especially if Restylane products without lidocaine will be injected. have received information regarding when and what topical anesthetics will be used, and information regarding contraindications, warnings/ precautions of use of these products and potential side offects.

Yes

My treating practitioner has also informed me that, depending on the treated area and injection technique, effects from the Restylane treatment can last 6-12 months (lips around 6 months), but this period may vary, either longer or shorter. Follow-up treatment helps maintain the desired correction.

Yes

I have responded to questions pertaining to any hypersensitivity to anaesthetic agents and to my medical history honestly.

Yes

I have informed my practitioner of all my previous aesthetic treatments, including injections, surgeries, chemical peels etc.

Yes

I have read and understood the above and hereby consent to treatment with Restylane products.

Yes

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