Hyaluron Pen Consent Form

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Thank you for your interest in the Hyaluronic Pen Treatment. This form is intended to provide you the information you need in order to make informed decisions about the treatment. Please write your name, info and read through below. Please fill out all the information required before treatment

INTRODUCTION

The Hyaluron pen is a needle free device that uses compressed air pressure to push filler into the skin. The Hyaluron Pen treatments involve infusing Hyaluronic Acid into the skin. This smoothes out wrinkles and restores volume. Hyaluronic acid is a natural, hydrating substance found in your skin tissue. The amount of Hyaluronic acid decreases as we age. This treatment is intended to retain Hyaluronic acid in our skin. The infusion of Hyaluronic Acid into the lips can last 6-12 months+ with touch up maintenance & proper care. Since this is not permanent, a periodic treatment may be required for body retention.

PATIENTS THAT MAY NOT BE ELIGIBLE FOR THE TREATMENT

Due to certain health conditions, some may not be allowed or may be evaluated further to take this treatment. This is for the protection of the health and safety of the patient. We have listed here the following conditions that may prevent the patient to undergo the Hyaluronic Acid treatment and thus the lip technician must be notified:

Those who had allergic reactions to hyaluronic acid products

Those who are anaphylactic or have a history of a serious allergic reaction

Those who are pregnant or nursing a child

Those who recently had dental/facial surgery.

Those who have viral infections such as herpes or simplex (cold sores)

Those who are under medication

RISKS & PROCEDURES

The following are the possible risks & factors that Hyaluronic Acid treatment may cause (please check each item as an express of your acknowledgment)
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It is normal to experience tenderness at or around the treated area. This usually resolves within a few days to a week* This field is required.
I understand that I might experience this during or after treatment and I understand that this resolves typically from a few days up until a week
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Itchiness, redness, and/or swelling at or around the injection may occur. This occurence is normal and may happen after treatment and will subside within a few days to a week. Some patients may experience prolonged swelling and/or tenderness/pain at the injection site.* This field is required.
I understand that I might experience this during or after my appointment
I understand that these side effects are mild & temporary
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Photo and video is taken for our records. This may be used for educational or business purposes
I acknowledge photo & videos taken & used for business or education purposes
I decline having photos and videos taken
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Check if you have any of the following conditions/ allergies. If none, please click, “none”* This field is required.
Eczema
Herpes
Bleeding disorders
Pregnant or breastfeeding
Hyperpigmentation
None apply
Other
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Please list any allergies or conditions you may have or that ENHANCEDBYEMILIA should know about
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Persons taking medications have a higher risk of bruising and bleeding.* This field is required.
I understand that I might experience this
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The results of the procedure are not considered permanent. Multiple sessions may be required for optimal results. Building your lips is a process. * This field is required.
I understand I may need multiple sessions for desired results
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There are very rare cases where the injection of Hyaluronic cid into a blood vessel would cause to block the blood flow in the treated area or in distant areas causing tissue damage. This is called a hematoma. If this occurs, hematomas can be treated and will subside within a few days to a week* This field is required.
I understand that in the event I experience this, i need to take proper care of the site wound & am given instructions on how to do so
I understand this as a possible risk
Persons on medications such as ibuprofen may be at risk
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PRE & POST care instructions are super important to follow and can create a safer procedure for the client and lip technician. These instructions must be followed for a specific period of time* This field is required.
I understand this must be followed
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Asymmetry, where the correction on one side may be different from the correction on the other side of the face* This field is required.
I understand that this may happen. In such occurrence, I might need to return for additional treatment for correction purposes.
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i understand and accept such procedure. I have read and fully understand the risks mentioned above, as well as other risks which may not fully be known. Nonetheless, I understand and assume all the risks involved in the treatment. I release & discharge ENHANCEDBYEMILIA, & any affiliates from any or all injuries & damages that may occur during or after treatment

I declare that I am of legal age with the full legal capacity to execute and bind myself to this consent. I have had the opportunity to ask questions that are unclear to me and answers were given to me by the representative to my satisfaction.

By signing this form, I give my consent in full consideration and understanding without any representation
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Date
Date
Month
Day
Year
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Name
First Name
Last Name
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Phone Number
Please enter a valid phone number.
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Email
example@example.com
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I certify that I am 18 years of age or older, or that I have obtained parental consent for this procedure if required by law. Please upload a photo ID below for confirmation.
YESNO
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Signature
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