RESTYLANE MEDICAL HISTORY

Have you previously experienced hypersensitivity to any of the RESTYLANE products or other dermal/hyaluronic acid fillers?

YesNo

Have you ever experienced any hypersensitivity to lidocaine (a local anaesthetic)?

YesNo

Have you received Roaccutane treatment in the past 12 months?

YesNo

Do you suffer from any known allergies?

YesNo

If yes, please specify

Do you have a history of anaphylactic shock (severe allergic reactions)?

YesNo

Are you taking aspirin, steroids or anticoagulants?

YesNo

If yes, please specify

Are you currently taking any other medication?

YesNo

If yes, please specify

Do you suffer from any illnesses, e.g. angina, epilepsy. diabetes, HIV positive, hepatitis, auto immune disease (e.g. rheumatoid arthritis), depression, stress?

YesNo

If yes, please specify

Have you recently undergone major surgery?

YesNo

If yes, please specify

Are you currently undergoing dental surgery?

YesNo

Do you suffer from fainting or low blood pressure?

YesNo

Do you suffer from keloid or hypertrophic scarring?

YesNo

Do you have a needle phobia?

YesNo

Are you prone to bruising?

YesNo

Have you recently been exposed to the sun or sun beds?

YesNo

IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS 'YES' THE PRACTITIONER MAY DECIDE THAT YOU ARE NOT SUITABLE FOR TREATMENT.

PRECAUTIONS

CONSIDERATIONS