Consent Form

Step 1 of 2

Patient Name *

Date of Birth *

Address

Telephone *

Email Address *

Botulinum Toxin (BOTOX) & Dermal Fillers PATIENT CONSENT FORM

Please complete the following questions

MEDICAL HISTORY

Please complete the following medical questionnaire.

Have you previously been treated with Botox or Dermal Fillers? *

Are you Pregnant or Breastfeeding? *

Are you currently receiving any medical treatment(s) (GP referrals, Hospital investigations, Treatments, Surgeries, IVF etc?) *

Are you on any medication(s) or have been taking in the last 4 weeks? *

Do you have any Allergies? *

Do you have a history of Anaphylaxis? *

Have you recently taken any Antibiotics (Gentamicin) in the last 2 weeks? *

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

Heart Problems including irregular heartbeat or Angina? *

Blood or Bleeding Disorders *

Neurological Problems (i.e. Muscle Weakness/ Motor Neurone Disease/ Myasthenia Gravis *

Inflammatory Skin Conditions such as Acne or Cold Sores? *

Do you tend to develop Hypertrophic (Keloid) Scarring? *

Do you require Hyalase treatment (Filler Dissolving)? *

BOTULINUM TOXIN CONSENT FORM*

INSTRUCTIONS This is an informed consent document that has been prepared to help inform you concerning Botox injections and the risks involved. It is important that you read this information carefully and completely. Please tick each page, indicating that you have read the page and sign the consent at the bottom prior to your treatment.

INTRODUCTION BOTOX injections involve a series of small injections in order to weaken the chosen muscles for example on the brow or below the eyes. Weakening of the injected muscles begins to be apparent after 2-3 days with the peak effect being reached after 10-14 days. Results can last 3-9 months. The procedure can be repeated after 3 months; however, injections given less than 3 month intervals may reduce the efficacy of the injections.

RISKS OF BOTOX INJECTIONS Every procedure involves a certain amount of risk, and it is important that you understand that risks involved. An individual’s choice to undergo a procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience these complications, you should discuss each of them with your practitioner to make sure you understand the risks, potential complications, and consequences of BOTOX injections:

Unsatisfactory Outcome/Temporary loss of function of nearby muscles Temporary Double Vision/ Migraine Hypersensitivity, Allergic response, Anaphylactic reaction (rare but can occur) Asymmetry of facial expressions Muscle weakness, twitching Bruising/swelling/skin redness Stinging/burning Headaches Drooping of the eyelid or eyebrow (ptosis)/local muscle weakness, double vision, dry/teary eyes Hives, feeling faint, nausea or flu like symptoms, tiredness Swelling of the face or throat, dry mouth, difficulty swallowing Infection at treatment site Period to take effect, further treatment needed, remaining muscle movement General Complications: Stinging/tingling/burning/bruising/swelling Injection site bleeding/skin redness around treatment area.

I have read, understood and agree to the information listed above.

DERMAL FILLER CONSENT FORM*

INSTRUCTIONS This is an informed consent document that has been prepared to help inform you concerning Dermal Filler injections and the risks involved. It is important that you read this information carefully and completely. Please initial each page, indicating that you have read the page and sign the consent at the bottom prior to your treatment. INTRODUCTION Dermal fillers are used to correct volume loss, shape, contour and reduce the appearance of fine and/or deep lines.

They consist of Hyaluronic acid which is a naturally-occurring gel produced in the body, which is injected into the treatable area. Fillers consist of local anaesthetic gel which minimises discomfort. The results can often be seen immediately after injection and can last anything between 6-18 months. RISKS OF DERMAL FILLER INJECTIONS Every procedure involves a certain amount of risk, and it is important that you understand that risks involved. An individual’s choice to undergo a procedure is based on the comparison of the risk to potential benefit.

Although the majority of patients do not experience these complications, you should discuss each of them with your practitioner to make sure you understand the risks, potential complications, and consequences of dermal filler injections: Hypersensitivity, Allergic response, Anaphylactic reaction (rare but can occur) Formation of nodules (lumps) around the treated area Slight visibility/palpability of the product under the skin Persistent bruising/ swelling which may last up to several weeks Infection/abscess formation following treatment, eruption of cold sores Small/Very Rare possibility of filler being injected into a blood vessel which could lead to blockage of the blood flow to the area supplied by the blood vessel (Vascular Occlusion) causing skin soreness, pain, coldness, numbing and discoloration.

Please contact the clinic as soon as possible in this instance on 07929340277 or email- info@refineuk.com. Perfect symmetry may not be achievable. Limited or non-response to treatment or Unsatisfactory Outcome Extremely rare risk of blindness if filler is injected into certain anatomical sites, such as the Glabella, Nasolabial folds and the Nose. The practitioner will discuss this during the consultation and provide advice on what to do post treatment(s). If you are not sure please ask anything listed above during your consultation or prior to your consultation with one of our staff memebers, who will help advise and guide you.

I have read, understood and agree to the information listed above.

Patient Consent to Treatment/ Procedure*

I have read a copy of the foregoing consent for the procedure, understood the side effects and possible complications related to my treatment, accept these facts, and hereby authorise RefineUK to perform the procedure of Botulinum Toxin/ Dermal Filler injections. Please Note: Due to the subjective nature of the treatment it is not possible to guarantee results.

Longevity of treatment results may vary between individuals. Patients can react differently to the same treatment. List of possible risks and complications is not exhaustive. My medical practitioner will take photos or videos taken before or after my treatment for the purposes of my medical records. I agree to these photos being kept confidentially with my medical file and agree to photos being taken.

I have read and agree to the terms & conditions listed above

Date

I am happy for my photographs to be used by RefineUK *

I am happy for my photographs to be used by Intraline (DermalFillerManufacturer) *