This form is not just a formality – it’s a record of your decision to consent to a procedure having considered the risk of both positive and negative outcomes and medical risks listed below, and the impact they may have on your well-being. Please sign the box below to confirm you have read, understood and discussed each section as required with your clinician. What is being injected? Hyaluronidase is an enzyme that breaks down dermal fillers made of hyaluronic acid into small sugars which easily disperse. Risks of the procedure include but are not limited to: INJECTON RISKS Trauma during the procedure is caused by needles and cannulas passing through tissue, and includes bleeding, bruising, haematoma (a larger collection of blood in the skin, outside of blood vessels), damage to underlying structures including veins, arteries, nerves, salivary glands, lymph nodes, bone, muscle and other soft tissue structures are possible. In rare cases this could cause continuous problems in appearance, sensation or function and may require medical intervention to treat or may be permanent. Most traumatic injuries heal completely on their own. REACTIONS Allergic reaction including anaphylactic shock are possible, they occur at a rate of between 1/2000 and 1/100 depending on the data source. Anaphylactic shock has a mortality rate of 0.3% - 5% depending on the study. An allergy test can often identify this risk prior to full exposure. Local reactions include oedema, erythema, pain and itching, urticaria and angioedema. SIDE EFFECTS Hyaluronidase dissolves hyaluronic acid including molecules made by your body and previous treatments that you may wish to preserve could also be dissolved. You therefore could notice a reduction in skin elasticity and volume and associated asymmetry which typically would last a few days. It is common to experience bleeding, bruising, swelling or oedema and redness near the injection site. TREATMENT FAILIURE It is possible that procedure will fail to remedy the problem as often hyaluronic acid is not the sole cause of lumps, bumps or reactions, which may be caused by other materials. Additionally, if you have received dermal filler injections elsewhere, hyaluronidase may not be effective in dissolving the product if hyaluronic acid was not used. COMPLICATIONS FROM INFECTION There is a small risk of introducing infection, and a theoretical risk that pre-existing infection could spread further if hyaluronidase is injected into the area, risking septicaemia, though there are no recorded cases. LIMITATIONS If you are pregnant or breast feeding, this treatment is not recommended. ADDITIONAL APPOINTMENTS Further treatments may be necessary to achieve the desired effect, and further charges will apply if an additional appointment is required and more product is used. DISSATISFACTION With all treatments the degree of improvement cannot be predicted or guaranteed. The outcome’s subjective nature means dissatisfaction is a possible outcome regardless of effectiveness of treatment. Some patients may be more or less sensitive to the effects of the treatment and occasionally the treatment does not work at all. By signing/completing the name field below I confirm that: – I have read this form carefully and considered the side effects, risks, complications and uncertainty of the outcomes and decided the treatment is still in my best interests - I confirm I do not have any known allergies to hyaluronidase, and to my knowledge I do not have any active cancers in the treatment area - I have been given the opportunity to ask questions, and these have been answered to my satisfaction - I have been given the opportunity to discuss all of the details of the treatment, my past treatments and my past medical history with the injector, and shared all the information the injector needs to plan the treatment - I understand some patients may be more or less sensitive to the effects of the treatment and occasionally the treatment does not work at all. This is a chance I am willing to take and I agree to be personally and fully responsible for all fees and payments related to my treatment, and I understand that no refunds are issued due to all of the above - I agree to pay additional fees associated to the treatment if a further appointment or further product is required – My treating practitioner has given me the time to consider the treatment – I have not knowingly withheld any relevant medical history or surgical information - After treatment, I agree to follow the Aftercare Regime instructions given to me by the clinic - I understand photographs are taken and stored for 7 years as part of my clinical record - I consent to anonymised photographs of my treatment to be used by the clinic for promotional and educational purposes. I understand that I will not be entitled to any payment as a result of these images/videos. BY COMPLETING THIS FIELD YOU ARE ADDING YOUR SIGNATURE TO THIS FORM.