Consent form

Botulinum A ToxinDermal Fillers (Hyaluronic Acid) Skin and Under Eye BoostersHyaluronidase (Hyalase)Fat Dissolving Injections (Deso Face / Body or Lemmon Bottle)

This form is not just a formality - it is a record of your decision to consent to a procedure having considred the risk of both positive and negative outcomes and medical risks listed below, and the impact they may have on your well-being.

BOTULINUM A TOXIN

What is being injected?

Botulinum Toxin may be branded Azzalure, Botox or Bocouture is a purified protein produced by the bacterium clostridium botulinum. The product causes muscle relaxation and suppresses sweating for 2-6 months on average (with wide variation between individuals) by temporarily disrupting nerve activity to muscles and sweat glands. By signing this form you agree and understand that some treatment areas are given off label as deemed appropriate by the prescribing clinician.

What are the side effects and risks?

- Transient headache, swelling, bruising, bleeding, pain, twitching, itching, puffiness/oedema around the eyes or numbness or other changes in sensation.

- Allergy including anaphylaxis is possible but very rare

- Asymmetry (unevenness)

- Temporary drooping of facial features, including eyebrows, cheeks and mouth.

- Dry eyes

- Double vision or blurred vision

- The theorectical risk of complications unique to certain individuals or so far unknown.

I Agree

LIMITATIONS AND ALTERNATIVES: Occasionally the treatment wears off very quickly or does not work at all. Botulinum Toxin is best at treating dynamic facial lines; those caused by facial muscle activity, lines present at rest may or may not improve and can be unpredictable. I have considered alternatives to treatment, including doing nothing, topical creams, chemical peels, laser treatments, surgical denervation, forehead / brow lift, facelift, or hyaluronic acid treatments and elected that at this time Botulinum toxin is the best option for me.*

I Agree

DERMAL FILLERS

What is being injected?

Hyaluronic acid injectables include branded products such as Juvederm, Restylane, Boletero, Profhilo, Lumi-eyes, illuna LUNA and others to improve the appearance of lines, correct volume loss and alter proportions. They include in their makeup mainly water, hyaluronic acid, lidocaine anaesthetic, and stabilising molecules.

What are risks of injection?

Trauma during the procedure is caused by needles and cannulas passing through tissue, and includes bleeding, bruising, haematoma (a larger collection of blood in the skin, outside of blood vessels), damage to underlying structures including veins, arteries, nerves, salivary glands, lymph nodes, bone, muscle and other soft tissue structures are possible. In rare cases this could cause continuous problems in appearance, sensation or function and may require medical intervention to treat or may be permanent. Most traumatic injuries heal completely on their own.

I Agree

INFECTION: Bacterial, viral or fungal infections can occur post procedure. Infections can cause redness and swelling and resolve or progress into abscesses which can be slower to recover. Rarely infections occur months later as "biofilm reactions". Symptoms include itching, and a lumpy or "thick" feeling at or just under the skin. Injections into the lip area could trigger a recurrence of cold sores (Herpes simplex infections) which may require treatment. These problems may resolve in time, but medical intervention may be required in some cases, and long-term effects may persist in rare cases.*

I Agree

REACTIONS: Reactions rarely occur but can include an immediate reaction causing swelling, and very life-threatening anaphylaxis. Delayed reactions localised to the skin can cause nodules, lumps or bumps or very rarely sterile abscesses. These may occur soon after the procedure or months later. They may require treatment and may leave permanent effects on the appearance, sensation and function of the areas affected. The chance of a reaction is reported to be 0.5% or 1 in 200. The chance of delayed reaction increases if you have active autoimmune disease or an active immune system including viral or bacterial infections elsewhere.*

I Agree

BLOOD VESSEL BLOCKAGE: In rare instances the blood supply can be blocked by filler. This can cause local tissue injury called "necrosis", which can result in permanent scarring. There are extremely rare cases in which blood supply to the eye or parts of the brain being affected causing blindness and stroke. Seeking help immediately if you suspect blood vessel occlusion is vital to prevent scarring.*

I Agree

HYALURONIDASE (HYALASE)

What is being injected?

Hyalurondase is an enzyme that breaks down dermal fillers made of hyaluronic acid into small sugars which easily disperse. Risks of the procedure include but may not be limited to:

What are risks of injection?

Trauma during the procedure is caused by needles and cannulas passing through tissue, and includes bleeding, bruising, haematoma (a larger collection of blood in the skin, outside of blood vessels), damage to underlying structures including veins, arteries, nerves, salivary glands, lymph nodes, bone, muscle and other soft tissue structures are possible. In rare cases this could cause continuous problems in appearance, sensation or function and may require medical intervention to treat or may be permanent. Most traumatic injuries heal completely on their own.

I Agree

REACTIONS: Allergic reactions including anaphylactic shock are possible, they occur at a rate of between 1/2000 and 1/100 depending on the data source. Anaphylactic shock has a mortality rate of 0.3 to 5% depending on the study. an allergy test can often identify this risk prior to full exposure (i.e. Patch test). Local reactions include oedema, erythema, pain and itching, urticaria and angiodema.*

I Agree

SIDE EFFECTS: Hyaluronidase dissolves hyaluronic acid including molecules made by your body and previous treatments that you may wish to preserve could also be dissolved. You therefore could notice a reduction in the skin elasticity and volume associated asymmetry which would typically last a few days. It is common to cause bleeding, bruising, some swelling or oedema and redness near the injection site.*

I Agree

FAT DISSOLVING THERAPY

Injectable options I can consider?

DESO Face / Body: Deoxycholic acid is an enzyme that breaks down dermal fillers made of hyaluronic acid into small sugars which easily disperse.

OR

Lemon Bottle: Bromelain, Riboflavin (Vitamin B2) and Lecithin. Derived from pineapples, bromelain is a potent digestive enzyme with anti-obesity properties. It triggers fat breakdown and reduces inflammation.

Deoxycholic acid-based fat dissolving - DESO Face / Body or AqualyxLemon Bottle

RISKS OF FAT DISSOLVING PROCEDURES INCLUDE BUT MAY NOT BE LIMITED TO:

What are the limitations and risks of injection?

I understand that only in small areas will one treatment session of fat dissolving be effective and it's likely that a course will be required, typically 3-6 treatments 4-6 weeks apart.

Trauma during the procedure is caused by needles and cannulas passing through tissue, and includes bleeding, bruising, haematoma (a larger collection of blood in the skin, outside of blood vessels).

Damage to underlying structures including veins, arteries, nerves, salivary glands, lymph nodes, bone, muscle and other soft tissue structures are possible. In rare cases this could cause continuous problems in appearance, sensation or function and may require medical intervention to treat or may be permanent. Most traumatic injuries heal completely on their own. More commonly but still rare (less than 0.1%), is the potential for significant inflammatory reactions leading to small areas of granuloma (nodules). These nodular lumps may persist beyond 6 weeks

I Agree

SIDE EFFECTS: Swelling and pain is to be expected. The area is often warm and some numbness is common. Local reactions including local swelling, erythema and hyperpigmentation, pain and itching, urticaria are to be expected and considered to be an expected reaction. A degree of sweating, nausea and diarrhoea may be experienced. We advise drinking plenty of water and avoiding excess alcohol. I understand that the area may look worse before improvements are seen.*

I Agree

AFTERCARE: I confirm that I will read and follow the aftercare advice recommended by the ReNu team. This includes but is not limited to refrain from applying any kind of cosmetics on to the treated area for 12 hours following my injectable treatments. I understand that I must avoid immediate exposure to heat sources during the days following treatment (eg. sunlight, UV radiation, jacuzzi, sauna). I understand that I should refrain from vigorous exercise for 24 hours following my treatment unless instructed differently. I understand that it is not advised to consume alcohol or anti-inflammatory drugs for at least 24 hours post procedure*

I Agree

DISSATISFACTION: I understand that with all the treatments the actual degree of improvement cannot be predicted or guaranteed. The outcome's subjective nature means dissatisfaction is a possible outcome regardless of effectiveness of treatment. I understand that the effect of all treatments may gradually wear off and additional treatments may be necessary to maintain/achieve the desired effect.*

I Agree

AGREEMENT: By signing this form, you agree that you have read this form carefully and considered the side effects, risks and uncertainty of the outcome and decided that the treatment is still in your best interests at this moment in your life. You have discussed all the details of the treatment plan, past treatments and your medical history with your clinician and shared all the information your clinician may need to plan a treatment. You agree that the balance of the benefits and risks to your overall favour the use of this injectable treatment. I understand that the primary treatment of side-effects and complications is included in the cost of the procedure and therefore no refunds are issued due to any of the above occurring. In understand that photographs are stored for 7 years as part of my clinical record*

I Agree

Name*

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Date*

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CONSENT TO TREATMENT: