Medical History and Consent Form

Please note that this medical consent form will be kept confidential and will only be viewed by the Aesthetic Practitioner and clinic team responsible for you whilst undergoing treatment at this Cosmetic Injectables clinic. Your details will not be available to third parties and are stored securely.

If any of the answers on this consent form raise concern for your Aesthetics Practitioner you may be contacted to discuss further or alternatively, these may be discussed at the time of your consultation.

 
Patient Details
Medical History

Are you attending or receiving treatment from a doctor or specialist?

Are you taking any medication, or herbal remedies (including Antibiotics, Anticoagulants, Muscle Relaxants, St. Johns Wart, Roaccutane)?

Are you taking blood thinning medication (Aspirin, Plavix, Warfarin)?

Are you allergic to local anaesthetic injections, lignocaine, adrenaline or EMLA/ANESTOP/LMX4 cream?

Do you have any known allergies or a history of anaphylaxis (a life-threatening allergic reaction)?

Have you suffered from or had any of the following conditions?

Heart problems including an irregular heartbeat or angina

High or Low Blood Pressure or circulation problems including Raynaud’s Syndrome

Epilepsy/Blackouts

Blood disorders/leukaemia/lymphoma/anaemia/cancer

Autoimmune disease, arthritis or recurrent sore throat.

Diabetes

Contact Dermatitis/Eczema

Keloids (hypertrophic scarring) or recent scar tissue (6 months) This is more common in dark-skinned individuals. See here for a picture

Easy bruising

Cold Sores

Psychiatric Illness/Depression

Do you use sunbeds or sunbathe?

Do you play a woodwind or brass instrument? (Because Botulinum Toxin softens wrinkles through its effect on muscles, it is important that you avoid treatment with Botulinum Toxin around the mouth if you play either of these families of instruments).

Are you pregnant/planning pregnancy/engaged in IVF treatment or are you breast-feeding?

Have you had a consultation or been treated with dermal filler, Botulinum Toxin, laser, chemical peels or microderm abraision before?

Have you had an allergic reaction to any dermal filler or Botulinum Toxin product?

Have you had a consultation or had plastic surgery of the face or neck or are you planning to have surgery?

Optional

Before and after photos are always taken to help assess treatment — these are confidential. However, I give my written consent for my photos to be used to show to future patients, and for marketing purposes.

Treatments

See the available treatments in the photo at the top of this page. Please ask your practitioner if you would like to discuss a treatment which isn’t mentioned above.

I hereby consent to the following:

I have no known allergy to local anaesthetic cream or injections and understand that either or both may be required as part of my treatment.

I have been informed about the risks and possible side effects of treatment and accept these risks as my own. I have understood and correctly completed the medical history form.

An undesired cosmetic effect, such as an unexpected appearance after treatment, can usually be avoided by clear communication between patient and Healthcare Professional.

Patient Signature

By submitting this form you are consenting to store your data privately on our system. Your private data will be held in accordance with data protection regulations.

Dermal Filler is the synthetic form of a natural substance found in human tissues (Hyaluronic Acid ). It can be injected directly beneath the skin to provide cosmetic benefits. It is effective immediately and can last from 6-12 months.

After treatment, you are advised to avoid wearing makeup over the injection sites for 12 hours to reduce the risk of skin infection. There is still a very small risk of infection with this treatment which may require treatment with antibiotics.

Potential complications and side-effects of filler include:

  • Bruising, bleeding, discomfort, itching for several days.
  • Rarely discolouration of the injection site, necrosis (death of skin), abscess formation, granulomas (abnormal growth of skin), skin infection, hypersensitivity and haematomas (large bruises) have been reported. Indurations or nodules may develop at the injection site — if any of these symptoms persist for more than 1 week, consult with the practitioner who treated you.
  • When using dermal filler to treat frown lines, smile lines (nasolabials / nose-mouth lines) there is a very small risk of skin damage requiring plastic surgery or even irreversible blindness. Feel free to ask your practitioner what precautions they will take to minimise this risk.

Dermal Filler Consent Signature

Botulinum Toxin (commonly referred to as the brand name ‘Botox’) is a purified bacterial toxin used worldwide for the reduction of facial wrinkles.

The time period before the Botulinum Toxin treatment is effective is 2-14 days. The treatment will last between 3-9 months.

Potential complications and side effects of Botulinum Toxin include:

  • Ptosis (eyebrow and/or eyelid) — especially if treating forehead.
  • Unwanted arching of the eyebrows if treating crows feet/forehead but especially frown lines.
  • Bruising and swelling at site of injection or a black eye.
  • Treatment may not work — everyone is different. Rarely, wrinkles can become worse.
  • Migraine, Temporary double vision, possible temporary numbness.

Botulinum Toxin Consent Signature

I have been advised that it is my responsibility to ensure that I inform the clinic my practitioner about any changes in my medical history, submitted here previously.

I understand the following regarding laser hair removal:

  • The aim of treatment is to reduce unwanted hairs or to reduce persistant skin irritation caused by shaving.
  • Prior to treatment I may require a patch test to ensure my safety
  • I consent to having photographs taken (when indicated) for the purpose of clinical assessment
  • I understand that photographs taken and information provided will be stored, processed and secured as part of my client records in accordance with the Data Protection Act.
  • I understand that results from the treatment may vary considerably with each individual, and that the clinic cannot provide a guarantee as to the success of the treatment.
  • I understand that a course of treatments may be necessary to achieve satisfactory results.
  • I understand that after treatment, redness and/or swelling of the area may be present. I also understand that there may be short­term side effects such as mild burning or blistering, hypo/hyperpigmentation, as well as, in rare cases, scarring or permanent discolouration. I understand that following the recommendations within the Aftercare sheet provided will help reduce the risk of these complications occuring.
  • I realise that during the procedure and shortly after, I might experience an itching sensation which will vary in degree, depending upon hair density, area sensitivity and treatment head used. This should not last long. A mild “sun­burn” sensation may follow for typically up to one hour and this can be reduced by applying cooling and soothing creams
  • I understand that perifollicular erythema/oedema (similar to shaving rash) may develop for a short period following treatment. This may be reduced by applying cooling/soothing/anti-­inflammatory creams
  • Micro­crusting (scabs) may develop over some areas following treatment. These are more likely to occur as a result of treatment to very dense and coarse hair and may take 5 - 10 days to flake off. I realise that during this time it is important not to manipulate or pick at these, and that doing so may lead to scarring
  • Bruising may rarely occur and may last several days
  • I understand that sun exposure or tanning of any sort is not aligned with the pre and/or post­care instructions and may increase the chance of complications
  • I am satisfied that I have been fully informed of the procedure, the potential risks and benefits and have read the Aftercare sheet provided.
  • I have been given the opportunity to ask any questions that I have regarding this treatment including Aftercare.
  • I acknowledge that I have read this consent form and that I understand the information provided within.

Do you have problems relating to hair growth?

Do you have a history of pigmentation changes?

Have you/do you plan to expose your skin to natural or artificial sunlight during the four weeks before and after treatment?

Do you suffer from Lupus, Porphyria, Vitiligo or Psoriasis?

Do you have a history of Skin cancer?

Do you have a history of Livedo reticularis or Erythema ab igne?

Have you taken Isotretinoin or Retinoic acid within the past 6 months?

Have you a tattoo or dysplastic nevi on the requested treatment area that should be protected?

My signature certifies that I have duly read and understood the content of this informed consent form and gave accurate information about my health. I hereby freely consent to have laser hair removal with the machine I have discussed with my practitioner.

Laser Hair Removal Consent Signature

I understand that whilst the tattoo removal laser machine, discussed with my practitioner, is approved for the removal of tattoos, results may vary with different tattoos.

I understand that there is a possibility of rare side effects such as scarring and permanent discolouration as well as short term side effects such as reddening, mild burning, bleeding, swelling, temporary bruising and discolouration of the skin.

These effects have been explained to me.

The experience of many practitioners is that dark coloured tattoos (black and dark blue) respond best to laser treatment. Bright colours are more difficult to treat and subsequently may not fade as well.

I have discussed the pricing for tattoo removal with my practitioner.

I understand that there are other treatment options available and I have been given the opportunity to discuss these with my practitioner.

With all of the above in mind, I have decided to proceed with this treatment for tattoo removal. I have read and understand this agreement and all my questions have been addressed and answered to my satisfaction. I agree to the terms of this agreement.

Laser Tattoo Removal Consent Signature

This treatment will be carried out using an Intense Pulsed Light (IPL) or Aculight System unless otherwise discussed.

The principle on which this treatment is based is as follows:

  • Photothermolysis. This means destruction by heat derived from light. Unwanted pigment or pigment in hair will absorb the energy (heat) from the light and will subsequently be destroyed.
  • Phagocytosis. This is the body’s own method of “mopping up” the detroyed vessel.

A test area must be carried out on every patient before treatment can be commenced. The purpose of this is:­

  • To demonstrate the procedural method to you, the patient.
  • To allow you to experience the feeling of the laser on your skin.
  • To show how the skin will look after the treatment.

Following treatment the skin may look red, it may swell, there may be bruising and in rare cases, there may be blistering. These are all temporary and the skin should not be harmed. However there is a minimal risk that scarring may occur.

The number of treatments will depend on the individual and the area being treated.

Post treatment­, cold water can be applied to the area and SPF 35 cream should be applied daily.

Your practitioner will endeavour to provide the best treatment possible but can not guarantee the final outcome.

Tanned skin (natural or artificial) cannot be treated as this will increase the risk of blisters and possible scarring.

Hypopigmentation (an area of pale skin) or hyperpigmentaiton (an area of darker skin) are possible side effects. These symptoms are usually not permanent but your practitioner cannot guarantee that normal pigmentation will return if these side effects do occur.

Please read the statements below before signing your name in agreement.

  • Any terms above that I did not understand have now been explained to me in a way that I can understand.
  • Due to the nature of the IPL, I understand that I will wear the safety eyewear supplied throughout the entire procedure.
  • I understand the treatment protocol and accept the risks to undergo this procedure and any questions that I asked have been answered.
  • I hereby indemnify the IPL practitioner, the clinic owners and their staff and the manufacturer of the equipment from any claims whatsoever.
  • The cost per treatment will be given to the patient at the time of the test patch consultation.
  • Payments are due at the time of treatment.
  • I fully understand the payment schedule and have agreed to the cost as written in the payment schedule.

I, the patient, acknowledge that before signing this agreement and consent form, I have read and understood both the information above and the downloadable Aftercare sheet.

Laser Skin Rejuvenation Consent Signature

Teosyal tear trough description

What is Dermal Filler?

Dermal Filler is the synthetic form of a natural substance found in human tissues (Hyaluronic Acid ). It can be injected directly beneath the skin to provide cosmetic benefits. It is effective immediately and can last from 6-12 months.

Which Dermal Filler product is used?

Note that the tear trough / palpebromalar groove treatments are usually provided using Teosyal Redensity II Hyaluronic Acid, a type of Dermal Filler licensed specifically for this use. Some practitioners do use other brands of dermal filler for this treatment.

Can other dermal fillers be used to treat these areas?

Yes, but other fillers are more likely to migrate with time towards the outer part of the tear trough leading to the appearance of a lump. According to its manufacturers, Teosyal Redensity II does not form lumps if it is injected correctly.

What are ‘tear troughs’?

They are the dark ridges that develop below the eyes which are often worse in appearance when tired or dehydrated. These lines are notoriously difficult to treat and have been seen by many practitioners as a big challenge in non-surgical aesthetics.

What is involved in treatment?

The treatment typically involves 3 or 4 injections under each eye. Before this, the skin can be anaesthetised using a cream so that the whole procedure is virtually pain free. It typically takes around 5-10 minutes.

What is the treatment protocol?

Typically one treatment, with results lasting 9-12 months. Some patients decide, along with their practitioner to receive further treatment to these areas with more dermal filler; this should be discussed with the practitioner face-to-face.

Potential side effects

Note that these are similar nomatter what part of the face is treated with dermal filler.

Common and minor:

Bruising is possible. Whilst not usually as prone to bruising as some other areas of the face, bruising is still a possibility. If bruising occurs, this can be limited by applying pressure at the injection site. Bruises can be covered up with makeup but patients should wait at least 12 hours following treatment before doing so, to limit the risk of introducing infection through the injection site. As with any other injection, there is also a risk of bleeding, discomfort or itching for several days.

Very rare but more serious:

Rarely discolouration of the injection site, necrosis (death of skin), abscess formation, skin infection, granulomas (abnormal growth of skin), hypersensitivity and haematomas (large bruises) have been reported. Indurations (dimples) or nodules may develop at the injection site — if any of these symptoms persist for more than 1 week, consult with the practitioner who treated you. When using dermal filler to treat any part of the face, there is a very small risk of skin damage requiring plastic surgery or even irreversible blindness. Feel free to ask your practitioner what precautions they will take to minimise this risk.

Tear Troughs Consent Signature

Sculptra is a collagen stimulator used for facial cosmetics. The Sculptra product itself is not providing the filling action but instead causes a reaction in the skin, which forms new collagen. Depending on the area treated, skin type and injection technique the effect of Sculptra lasts approximately 2 years after the last treatment. Sculptra requires a series of treatments to achieve adequate filling for most skin defects. You should discuss your treatment plan fully with your Healthcare Provider before beginning treatment.

Sculptra is injected under the skin in the area to be treated (usually the face) using several injections per area. These injections are mildly painful. The treated areas will be mildly sore for up to 3 days after treatment. Your skin will be deeply massaged/manipulated by the practitioner after treatment. You may resume normal activity immediately.

Your skin may appear “lumpy” and mildly red or swollen for 24-48 hours after the treatment. This is normal. There may be mild bruising of the skin, especially if treatment is around the eyes, which may last for up to 7 days. If swelling is severe, pain or bruising is increasing, or fever develops, call the clinic where your Sculptra was administered. You will have puffiness (not severe) for up to 10 days after the procedure. This is simply the water used to carry the Sculptra product into your skin, and most of this is reabsorbed within the first week.

The effect of Sculptra is slow and gradual as your skin forms collagen around the product crystals. Your best results are seen about 3 months after your last treatment. Please be patient!

Other possible adverse events:

  • Temporary numbness or tingling in the treated area.
  • Temporary partial facial muscle paralysis (from the lidocaine anesthetic), lasting less than 2 hours.
  • Infection at the injection sites. This would be very rare and treated with routine antibiotics.
  • Small “bumps” rarely (~1%) form deep in the skin in the treated areas, which may or may not become visually apparent. This represents new collagen, which has formed deep in the skin.

Sculptra Therapy Consent Signature

Microneedling is a cosmetic procedure that involves repeatedly puncturing the skin with tiny, sterile needles. The technique may help with skin problems such as scarring, acne, wrinkles and lines.

While our Microneedling system is a safe procedure that is suitable for most people, it is not suitable for everybody. It must be advised that you should not proceed with this treatment, if you currently suffer from the following conditions:

Have you had Botox or fillers within the last 6 months?

Is the scar in questions to be treated less than 6 months old?

Do you suffer from any collagen vascular disease?

Do you have any bacterial or fungal infections?

Do you have Scleroderma?

Do you suffer from an Auto Immune Condition and/or presently taking any immune suppressors?

Do you suffer from Rosacea?

Do you suffer from acute/chronic skin conditions or benign/malignant lesions?

Do you suffer from seizures, black outs or epilepsy?

Do you suffer or have you suffered from any heart conditions or complaints?

Are you pregnant, or trying to become pregnant?

Are you breastfeeding?

Have you ever had an allergic reaction Latex or non-surgical products?

Have you ever had a reaction to topical anaesthetic?

The following conditions may not inhibit you from having the treatment performed, but the practitioner does need to be aware of them:

History of Eczema or Dermatitis?

Pigmentation problems including a history or of susceptibility to Keloid, raised/hypertrophic scarring?

History of Diabetes?

Psoriasis and any other chronic conditions?

Presence of raised moles?

Herpes simplex infection/cold sores?

Warts or raised lesions in area to be treated?

Any known allergies?

Have you recently used a sunbed, tanning products or had sun/UV exposure or sunburn?

History of actinic keratosis?

Thrombosis or any blood clotting problems?

Do you bruise easily?

Bleeding disorder or blood related illness, anaemia, sickle cell, thalassemia, hepatitis A/B/C or HIV?

Have you ever had an allergic reaction to Lidocaine or Propylene Glycol?

Are you currently taking any medications or using any topically prescribed creams?

Have you undergone any other form of cosmetic treatment or surgical procedure in the last 12 months?

Microneedling Consent Signature

I confirm that I have either discussed other treatment options for excessive sweating, with my own Doctor (GP), or I have decided that I do not wish to seek this advice. I understand that alternatives to botulinum toxin injections include special prescription deodorant, powders and surgery.

I am aware that it may be possible for me to receive this treatment free of charge, on the NHS, but I have chosen to instead receive this treatment as a private, paying customer.

I understand that underarm shaving is best avoided for 48 hours before or after treatment. I understand that shaving within this timeframe simply gives a slight increase in the risk of a skin infection.

Compensatory Sweating

I understand that commonly, underarm or palmar Botulinum Toxin Type A injections will lead to ‘compensatory sweating’. This is when stopping sweating in one area leads to increased sweating elsewhere - for example the back or thighs. Although this is very common, most patients will report high satisfaction levels in the overall outcome - presumably because they can tolerate sweating excessively elsewhere on their body more than in the area treated.

Pain

I understand that it is recommended that practitioners apply a strong anesthetic cream or gel prior to injecting. Following the application of this anaesthetic, pain during treatment of the underarm area is normally minimal. Treatment to the palms of the hands is more painful as it is a nerve-dense area.

I understand that the effects of treatment typically last 9-12 months but that this is not guaranteed as it varies between patients.

Hyperhidrosis Consent Signature

Reminders