The administration of Hyaluronidase is in order to help reduce the fullness and effects of prior administration of Hyaluronic acid.
We, (your practitioner and associates) have suggested the conservative use of Hyaluronidase. We have clearly explained to you that we cannot make any promise or guarantee that such administration will be effective. We have explained that if the first administration does not work we may have to do it again in the future. We will do clearly in an effort to help you with this problem and making every effort to avoid further injury. However you understand that the administration of Hyaluronidase may not help and may even cause you additional cosmetic and functional problems that may be permanent. It may cause contour irregularities, further asymmetry of the face and further worsening of the problem you already have. We have explained to you that if the main ingredient of the substance injected to your face was not Hyaluronic acid then this proposed treatment will not be effective on you. Further and additional treatments and surgeries may be required to treat your facial deformities and the financial burden and responsibility for all such additional expenses will be solely yours (the patient).
I, (the patient) fully acknowledge and agree that my practitioner and associates have fully explained the risks, benefits, and alternatives associated with the use of Hyaluronidase and that such use may compromise or reverse the overall effect of my previous procedure and I fully release my practitioner and associates of any and all claims and responsibilities associated with my previous procedure. My practitioner and associates have answered all of my patient questions to my complete satisfaction and I fully understand that using Hyaluronidase can alter my facial look as described above and I release my practitioner and associates of all claims and responsibilities in the use of Hyaluronidase. I understand all this information and wish to proceed with the administration of Hyaluronidase.
Possible side effects may include: allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Less serious side effects may include: pain or tenderness where the medication was injected; or swelling in any part of your body. This is not a complete list of side effects and others may occur. Call my practitioner and associates for medical advice about side effects.
BY SIGNING BELOW, I ACKNOWLEDGE AND CERTIFY THAT I, Client Name HAVE READ AND UNDERSTAND THE "CONSENT, RELEASE AND INDEMNITY AGREEMENT" FOR THIS PROCEDURE, AND THAT I AM SIGNING IT VOLUNTARILY.