Wansford Health clinic This page shows sample consent forms you would review and agree before having your first treatment at Wansford Health
The first form is for wrinkle relaxing treatments and the second for Dermal fillers
Sample CONSENT Wrinkle treatmemt
I confirm that _______________________________________________
who uses Wrinkle relaxing for cosmetic treatments has given me sufficient information to enable me to understand the use of the product. I have received information regarding the product’s contra-indications and potential side effects. I have been given the opportunity to ask questions about the proposed treatment.
When completing the medical history questionnaire, I have answered the questions fully and to the best of my ability. I have also given further details relating to my medical history when asked.
I confirm I have been informed that:
The wrinkle treatment injection is injected into the skin to correct wrinkles and lines of the forehead, around the eyes and in between the brow. Due to the use of a needle, there may be some bleeding at the injection site. As is expected for any injection procedure, pain/burning/stinging, swelling and/or bruising may be observed in association with the injection. This reaction may last for several days. Rarely headache, lowered eyelids, face pain, bruising, local muscle weakness have been reported. Further information is contained in the patient information leaflet provided with the product.
If any of these symptoms persist for more than one week, or if any other side effects develop please report them to the practitioner as soon as possible as they are best placed to help and advise you.
The aesthetic effects 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 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.
Statement of consent: I have been correctly informed about the treatment effects and I consent to the treatment detailed on this form.
Signed:______________________________________
Date:_______________________________________
ADVISED CONSENT DERMAL FILLERS
I have been given sufficient information to enable me to understand the use of the product for the approved indications.
I have also received information regarding contra-indications to the administration of products and potential side effects.
I have been informed that the treatment is carried out by injection, for the improvement of lines/wrinkles and folds of the skin, for lip augmentation and rehydration of the skin.
Some redness, swelling and occasional bruising may occur after treatment associated with possible discomfort, itching and discolouration at the injection site. Resolution is typically spontaneous within a few days.
As with all injectable treatments, there is a minimum risk of infection, vessel occlusion and hypersensitive reaction.
Persistence of inflammatory reaction for more than one week, or the development of any other side effects must be reported to the practitioner as soon as possible.
The effect and length of the results may vary depending on the condition of the skin, mechanical action in the treatment area, amount of product injected and technique for injection.
Lifestyle factors also affect the duration of the product.
Regular top-up treatments help to optimise the duration of the product.
Post Treatment: Following treatment, avoid sun exposure and sauna’s.
Avoid manipulation of the treated area and make-up, as instructed by practitioner.
I have been informed about the treatment effects of these ranges of products and I consent to the treatment detailed on this form.
The potential benefits and any risks have been fully explained.
Signed.......................................................................
Date..........................................................................
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