Date Of Appointment (Month/Date/Year) Full Name Mobile Phone Address City State Zip Email Date of Birth (Month/Date/Year) General Questions: Are you pregnant or breast feeding? - Select - Yes No Have you had a history of severe allergy/anaphylaxis? - Select - Yes No Are you currently on any medication? - Select - Yes No Have you previously received any Aesthetic Treatments? - Select - Yes No Have you had any dermal fillers, absorbable dermal fillers, semi – permanent dermal fillers? - Select - Yes No Have you been diagnosed with any auto – immune disease? - Select - Yes No Do you have any inflammatory skin conditions such as active acne and/or herpes (cold-sores)? - Select - Yes No Are you taking any steroids, blood thinners, aspirin, warfarin, apixaban, rivaroxaban? - Select - Yes No Do you suffer from any allergies, in particular allergies to hyaluronic acid or amide type anaesthetics or lidocaine? - Select - Yes No Do you suffer from untreated epilepsy? - Select - Yes No Have you ever had a raised scar? - Select - Yes No Have you been diagnosed with any cardiac conduction disorders? (Arrhythmia, atrial fibrivation/flutter, cardiac arrest, coronary heart disease and heart attack) - Select - Yes No Are you currently undergoing any dental treatment plan or have any loose teeth? - Select - Yes No Have you currently got any active infection or taking anti – viral medication, anti – fungal medication or antibiotics? - Select - Yes No This is a cosmetic procedure to enhance, volumise, repair or disguise signs of aging. If you have answered yes to any of the above questions, you will not be able to proceed at this time. If you have had filler in the last 12 weeks, you can only proceed if the brand you have had injected, is the same brand that is used in this procedure. To the best of my knowledge, I have answered all the above questions correctly. I understand that this record will be retained and be properly disposed of if I cannot proceed to treatment. You must agree before submitting. Electronic Aknowledgement Date Today (Month/Date/Year) Patch Test/Waiver: For liquid products used: I understand that a skin test can determine whether I will experience a reaction to the products used by the specialist within 48 hours of the treatment. However, I accept this will be inconclusive as to whether I will have an allergic reaction at any time in the future. I therefore waiver my option to an allergy test and thus wish to proceed with treatment. I have undergone or been offered an allergy test prior to initial treatment. In line with the relevant medical information and contraindications that will be discussed with my specialist, I release the specialist from liability related to any allergic reactions I may experience associated with either the application of any pre-treatment cream or any other products used before, during or after the procedure, either today or at a later date. I have been advised that Teoxane & Revolax products both contain injectable Lidocaine which can lead to analaphatic shock. I have been advised that Hyafilia Classic (Hylauronic Acid Filler) may lead to allergic reaction. I understand that an injectable allergy test cannot be carried out prior to this procedure. You must agree before submitting. Electronic Aknowledgement Date Today (Month/Date/Year) Informed Consent for HyaPenPro: I confirm that I have been informed that: Hyafilia Classic (Hylauronic Acid Filler) products are introduced into the Dermis to correct wrinkles/ of the face or skin or for lip augmentation. My Practitioner has explained the procedure to me and how the HylaPenPro sprays the product through the skin, without the use of needles. I have been made aware that Hyafilia Classic (Hylauronic Acid Filler) contain lidocaine, which may result in a positive anti – doping test and/or cause an allergic reaction and/or anaphylactic shock. I have been made aware that The Hyafilia Classic (Hylauronic Acid Filler) should not be used if I am taking drugs which inhibit hepatic function such as beta – blockers. I understand listed side effects of lip augmentation are known as follows: Redness, Swelling, Stinging, Itching, discomfort, bruising, abscess, granulomas, haematomas, indurations, discolouration, hyper-sensitivity. The majority of these side effects are associated with injecting the product into the lip tissue, not known side effects, of using the HyaPenPro to volumise the lip. I understand that the only product which can be used must be from the same range, if it is less than 12 weeks, since a previous treatment. I understand that the aesthetic effects will last an average of three to six months but will vary depending on the condition of the skin, area treated, amount of product used and lifestyle factors such as sun exposure and smoking. I further understand that due to the high vascularisation and action of the lip area, that the average life of treatment in the lip area, is less than in other areas of the face. I understand that any graphic, photograph or artwork used in HyaPenPro literature, is only representative of the treatment and my own treatment, is based on the plan originated today, with my agreement. I understand that after treatment I should avoid smoking and sun exposure for 12 hours. I should also avoid extreme freezing and or heat treatments, such as a sauna, for 14 days. My practitioner has provided me with enough information about the procedure to facilitate informed consent and has answered all remaining questions and I therefore consent to the described treatment. I have had enough time to consider and feel we have reached a therapeutic agreement based on the medical, aesthetic and outcome requirements listed as relevant for and or within the nature of the HyaPenPro treatment, with named product range. You must agree before submitting. Electronic Aknowledgement Date Today (Month/Date/Year)
