Forms

Purpose. Aesthetic Skin Expert promotes health wellness, healing, and rejuvenation of the skin. This type of skin care will also promote skin healing, beauty, prevent old age skin problems, and makes you look young.

Risks. There are still risks in this type of treatment and the dermatologists or the physician will explain everything to you. There is a non-invasive and invasive procedure which is why consent is always needed from the client.

Benefits. There are a lot of benefits that you will get from dermatology care. All the benefits and positive reasons why be thoroughly explained to you by the staff.

Confidentiality. All data that we gather from this form will be kept confidential and will not be released to anyone without your consent.

Questions. If you have any questions, please do not hesitate to contact us at 07590 062764 or email us at info@aesthetic-skinexpert.uk

I confirm I have been informed that:

BOTOX is indicated for the temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at maximum frown (glabellar lines); moderate to severe lateral canthal lines (crow’s feet lines) seen at maximum smile; moderate to severe crow’s feet lines seen at maximum smile and glabellar lines seen at maximum frown when treated simultaneously in adults, when the severity of these lines has an important psychological impact for the patient.

Like all medicines, BOTOX can have side effects, although not everybody gets them. In general, side effects occur within the first few days following injection. They usually last only for a short time, but they may last for several months and in rare cases, longer. These adverse reactions may be related to treatment, injection technique or both.

Diffusion of botulinum toxin into nearby muscles is possible when high doses are injected, particularly in the neck area.

As expected for any injection procedure, pain/burning/stinging, swelling and/or bruising may be associated with the injection. Speak to your doctor if you are worried about this.

Adverse reactions possibly related to the spread of toxin distant from the site of administration have been reported very rarely with botulinum toxin (e.g. muscle weakness, constipation, difficulty in swallowing, food or liquid accidentally going into the lungs which in some cases may lead to pneumonia). Injection of BOTOX is not recommended in patients with a history of dysphagia (difficulty to swallow) and impaired swallowing.

The chance of having side effects is described by the following categories:

please tell your doctor or pharmacist.

BOTOX should only be administered by medically qualified physicians with appropriate qualifications and expertise in this treatment and having the required equipment.

Too frequent or excessive dosing of BOTOX may increase the risk of antibodies in the blood which may lead to failure of treatment with botulinum toxin when used for this and other conditions.

The aesthetic effects of BOTOX last for an average of 3-4 months but will vary depending on the condition of the skin, area treated, amount of product injected, injection technique and lifestyle factors such as sun exposure and smoking.

After treatment, please avoid extreme facial expressions, alcohol consumption and applying make-up for 12 hours. Please avoid extreme sun exposure, UV light, freezing temperatures and saunas for 2 weeks after treatment.

I confirm that my treating practitioner has:

Provided me with sufficient information about the treatment detailed in the form in order to make an informed decision

Given me the opportunity to ask all remaining questions I may have about the treatment, and has answered them to best of their ability

Given me the time to consider the treatment

Received the relevant medical history information from me to the best of my knowledge

I therefore consent to receiving the described treatment by my treating practitioner.

I confirm I have been informed that:

The products in the VYCROSS Collection (JUVEDERM VOLUMA with lidocaine, JUVEDERM VOLIFT with lidocaine, JUVEDERM VOLIFT Retouch with lidocaine, JUVEDERM VOLBELLA with lidocaine, JUVEDERM VOLITE with lidocaine), are a non-animal, hyaluronic acid-based (sugar- based), non-permanent transparent gel which is injected to:

Restore facial volume (JUVEDERM VOLUMA with lidocaine)

Treat deep skin depressions, face contouring and volume restoration (JUVEDERM VOLITE with lidocaine, JUVEDERM VOLIFT Retouch with lidocaine)

Treat fine lines and medium- sized skin depressions as well as enhancement and pouting of the lips (JUVEDERM VOLBELLA with lidocaine)

Treat fine lines and for additional improvement of skin quality attributes su as hydration and elasticity (JUVEDERM VOLITE with lidocaine)

Treatment with JUVEDER VOLUMA with lidocaine may remain effective for up to 18 months; treatment with JUVEDERM VOLIFT, VOLIFT Retouch and VOLBELLA with lidocaine for up to 12 months; treatment with JUVEDERM VOLITE with lidocaine is proven to improve dermal hydration for up to 9 months. This will vary depending on the skin type, areas treated, the quantity of product injected, the injection technique and lifestyle factors such as sun exposure and smoking.

A touch-up session may be recommended a few weeks after the first session to increase the effects and maximise the results. You should be made aware that the products contain 0.3% lidocaine which may produce a positive result in anti-doping tests.

After an injection with either one, two, three, four, or five of the VYCROSS Collection products, inflammatory skin reactions (for example, redness, swelling, rash) which may be accompanied by itchiness or pain on the application of pressure, may occur. These reactions may last up to a week. Bruising, lumps or nodules may appear at the injection site. Very rarely, cases of discolouration or lightning at the injection area have been reported. Rare cases of necrosis (cell death), abscesses (collection of pus), granulomas (foreign body reaction) and immediate or delayed hypersensitivity (allergic reactions) have also been reported after hyaluronic acid injections and/or lidocaine, as have poor weak filling effects.

After treatment, please avoid extreme facial expressions, alcohol consumption and applying make-up for 12 hours. Please avoid extreme sun exposure, UV light, temperatures below 0 degrees of Celsius, saunas and steam rooms for 2 weeks after treatment. It is advisable to avoid strenuous activity or exercise for up to 24 hours and to avoid massaging the treated area. Try to sleep with the head elevated and avoid sleeping on the injected areas for one or two days.

The use, indications, contraindications (specific situations in which the five VYCROSS Collection products: JUVEDERM VOLUMA with lidocaine, JUVEDERM VOLIFT with lidocaine, JUVEDERM VOLIFT Retouch with lidocaine, JUVEDERM VOLBELLA with lidocaine, JUVEDERM VOLITE with lidocaine, should not be used) and the possible side effects have been explained to me. There are specific situations in which one, two, three, four or five VYCROSS Collection products should not be used, these can be identified from my medical history. I have accurately and truthfully answered all the questions regarding my previous medical and aesthetic treatment history to the best of my knowledge.

I was given the opportunity to ask questions and I am satisfied with the answers given.

If inflammatory reactions persist for more than one week, or if any other side effects appear, I will inform my medical practitioner who will treat appropriately. Whilst rare, such side effects may require treatment lasting several months before they disappear.

I have read and understood the post-injection recommendations and undertake to observe them.