Hyalase Consent Form
Date of Birth:
Consent for Treatment with Hyalase™ to Dissolve Hyaluronic Acid (HA) Dermal Fillers (Elective or Emergency Use)
Hyalase™ is an enzyme which breaks down hyaluronic acid. Hyaluronic acid is the component of dermal fillers, but is also naturally occurring in the skin and soft tissues.
Hyalase™ (hyaluronidase 1500 units) is licensed and commonly used to boost absorption or dispersal of drugs injected into the skin and has an off license use in aesthetic medicine.
Occasionally dermal fillers need to be dissolved when the treatment outcome is unacceptable, when an adverse reaction to the implant has occurred, or there is a possibility of vascular occlusion and/or impending necrosis (tissue death) which could lead to the compromise of healthy tissue.
Motivations and Expectations
Alternative Treatments I have been Advised I may Consider;
Acceptance of present condition
Massaging the area or leaving the dermal filler to break down naturally which may take several months dependent on the type of filler used and the area treated.
Common Side Effects Associated with the Injection
Pain or stinging sensation when the injection is performed.
Localised swelling, which may be marked in the first 24-72 hours.
Redness and or tenderness
Bleeding at the sites of injection
Bruising. Rarely, bruising may be severe and may persist for several weeks.
Numbness or itching of the area following injection.
Loss of volume beyond the loss of correction the filler provided.
Skin laxity which is expected to be temporary, but may be disfiguring until your own hyaluronic acid is replenished.
The results are unpredictable and more than one treatment 1-4 weeks apart may be necessary to achieve the desired result. Common side effects are expected to resolve spontaneously, within the first few days of treatment. Whilst not expected, it is possible that reactions described may persist for longer than expected and may inhibit your confidence to attend work or social events. You are advised to schedule treatment with this in mind, allowing time for common reactions such as bruising and swelling, to settle.
Uncommon Side Effects
Allergic Reaction– a small percentage of the population may be severely allergic to Hyaluronidase, particularly those who are allergic to bee stings. Hyalase™ administration can result in anaphylaxis a severe allergic reaction which in itself is life threatening and requires immediate medical attention and hospitalization.
I understand that though complications are uncommon, they do sometimes occur. It is possible that side effects not described may occur and indeed that a complication not previously reported may occur for the first time.
I understand if I suffer any adverse reactions that are not expected, or concern me, I must contact the clinic. An appointment will be made for me to be seen. The clinic cannot take responsibility for complications or results that have not been reported, assessed, documented and managed in a timely fashion.
I confirm that the medical health history form has been completed truthfully and I am fully aware that withholding medical information, including history of previous treatment, may be detrimental to the safe and optimal outcome of any treatment administered. If there are any changes in my medical history, I must inform the practitioner.
I confirm that I have been provided with verbal and written information about this treatment which includes aftercare and follow up advice. I agree to follow the aftercare advice and understand this reduces risk of adverse reactions and helps ensure optimum results.
I understand information about me will be treated as confidential and access to it restricted in accordance with the Data Protection Act, unless specific permissions given.
I consent to photographs being published for;
I have been advised the cost of the treatment will be £ and accept the terms of payment as per the clinic policy (terms and conditions).
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Your legal name
Your email address
Signed by Nina Bal
Signed On: 8th January 2020
If you have questions about the contents of this document, you can email the document owner.
Document Name: Hyalase Consent Form
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