Please read through the following consent forms and either email or text to confirm you have read and understood the consent form for the treatment you are booked in for ..
Before attending you must ensure you feel well and have no Covid 19 symptoms.
Arrive alone, on time and please don’t bring any children with you to the clinic.
Please wear a mask to your appointment, if you are mask exempt please rearrange for when we are no longer required to wear masks.
PLEASE NOTE YOU CANNOT HAVE ANY FILLER WITHIN TWO WEEKS OF YOUR COVID 19 VACCINE OR BOOSTER
IF YOUR VACCINATION OR BOOSTER APPOINTMENT IS WITHIN TWO WEEKS OF YOUR FILLER PLEASE CALL TO REARRANGE YOUR FILLER.
Please note all deposits are non refundable if cancelled less than 24 hours before your appointment. Please cancel or rearrange your appointment if you need to as soon as possible.
Patient Consent for Treatment During COVID-19 Pandemic
I understand that I am opting for an elective treatment.
I understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization and that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, social distancing is recommended. This is not entirely possible with my proposed treatment, however, I am satisfied that safety measures are in place to minimise risk as much as possible, and patient contact will be kept to an absolute minimum in line with medical need.
I understand the Management and Clinical Staff are closely monitoring the COVID-19 situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment, and I give my express permission to proceed.
I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. I understand that COVID-19 can cause additional health risks, some of which may not currently be known at this time, in addition to those risks associated with the treatment itself.
I have been given the option to defer my treatment to a later date. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired treatment
I confirm that I am not presenting with any of the following symptoms of COVOID-19 listed below:
- Shortness of Breath
- Loss of Sense of Taste or Smell
- Dry Cough
- Runny Nose
- Sore Throat
I confirm that if I develop COVID-19 symptoms following my treatment, or a known contact of mine develops symptoms, I will immediately inform the The White Rooms to enable appropriate measures to be put in place and contact tracing to commence.
I confirm that I understand that the usual top up follow up from any botox treatment will not be offered as standard. But is available if you feel you need it after 10 days.
If you are late for your appointment you may not be able to be seen.
Please ensure you come alone to your appointment.
Please remove all makeup before your appointment if possible.
BELOW ARE CONSENT FORMS
PLEASE SCROLL TO YOUR INTENDED TREATMENT AND READ ANY PRE TREATMENT ADVISE AND CONSENT FORMS
Botulinum Toxin Consent Form
Botulinum Toxin type A is a treatment for the temporary reduction of moderate to severe lines and wrinkles in the frown area and the crows feet. Botulinum Toxin Type A may also be used in other areas for improvement in the appearance of lines and wrinkles. The effects of the procedure typically last about 3 – 5 months. The results of the initial treatment will start to become noticeable after a few days, and continue to improve for up to two weeks.
Side effects of the treatment include bruising and swelling at the injection site. Other side effects are related to the action of the Botulinum Toxin on adjacent muscles and include raising of the eyebrow, drooping of the eye brow, and drooping of the eyelid. These side effects are transitory and will last as long as the effect of the treatment.
By reading and confirming that you you have understood this form you are agreeing that you understand the nature of the proposed treatment, including alternative options, the intended benefits and potential risks. You will have the opportunity to discuss any concerns regarding your treatment at you appointment.
Dermal Filler Consent Form
PLEASE NOTE YOU CANNOT HAVE ANY FILLER WITHIN TWO WEEKS OF YOUR COVID 19 VACCINE
IF YOUR VACCINATION APPOINTMENT IS WITHIN TWO WEEKS OF YOUR FILLER PLEASE CALL TO REARRANGE YOUR FILLER.
The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the Dermal Filler Treatment. This material serves as a supplement to the discussion you have with your nurse/other healthcare professional. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your nurse/healthcare professional at your appointment.
Treatment with dermal fillers (such as Juvederm, Restylane, Radiesse and others) can smooth out facial folds and wrinkles, add volume to the lips, and contour facial features that have lost their volume and fullness due to aging, sun exposure, illness, etc. Facial rejuvenation can be carried out with minimal complications. These dermal fillers are injected under the skin with a very fine needle. This produces natural appearing volume under wrinkles and folds which are lifted up and smoothed out. The results can often be seen immediately.
RISKS AND COMPLICATIONS
Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization, and/or extended outpatient therapy to permit adequate treatment. It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include but are not limited to: 1) Post treatment discomfort, swelling, redness, bruising, and discoloration; 2) Post treatment infection associated with any transcutaneous injection; 3) Allergic reaction; 4) Reactivation of herpes (cold sores); 5) Lumpiness, visible yellow or white patches; 6) Granuloma formation; 7) Localized necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs.
PREGNANCY AND ALLERGIES
I am not aware that I am pregnant. I am not trying to get pregnant. I am not lactating (nursing). I do not have or have not had any major illnesses which would prohibit me from receiving dermal fillers. I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to lidocaine.
PRE AND POST CARE INSTRUCTIONS
- Avoid skin irritation or intentional skin tanning. Sunscreen SPF 30+ is advisable for 1 week prior.
- Discontinue irritants for 4-5 days prior to treatment. This includes retinols, salicylic acid, and glycolics. May resume using these types of products 1 week after treatment if your skin feels ready/not sensitive.
- If using Hydroquinone, stop using it 3 days prior to treatment. If using Lytera (or other non-hydroquinone brightening products) you do not need to stop using these products prior to treatment.
- Arrive with clean skin if possible. There should be no lotion, oil, makeup or self tanning agent on skin.
- Patients with a history of diseases stimulated by heat, such as Cold Sores, must be treated with a prophylactic medication. Please let the provider know if this applies to you.
- Immediately after treatment, you may experience redness for 1-3 days. However, for more aggressive treatments this may last longer. Mild to moderate swelling and a sunburn sensation are both common post-treatment and may last 1-3 days.
- Treatment side effects may include: Discomfort, Excessive skin redness (erythema) and/or swelling (edema), Damage to natural skin texture (crust, blister, burn), Change of pigmentation (hyper- or hypo-pigmentation), Scarring, and Infection.
- A post-procedure moisturizer may be applied to the face. SPF is required daily.
- Check with the provider for personalized, detailed skin care regimen if adding additional products.
- Cooling compresses can help reduce discomfort.
- Makeup can be applied after 24 hours
- There are no restrictions on bathing except to treat the skin gently, avoid scrubbing/exfoliating, trauma or high heat to the treated area.
- Avoid sun exposure to reduce the chance of hyperpigmentation.
- Multiple treatments over a period of several months may be required to achieve the desired result.
Before the Treatment:
Prior to the treatment, please observe the following:
No Retin-A products or applications 12 hours prior to your treatment.
No auto-immune therapies or products 12 hours prior to your treatment.
No prolonged sun exposure to the face 24 hours prior to your treatment. The treatment will not be administered on sunburned skin.
On the day of the treatment, please keep your face clean and do not apply makeup.
If an active or extreme breakout occurs before treatment, please consult your practitioner.
Preparation time 2-4 weeks
The products recommended using: Tebiskin HYAL and Tebiskin EGF
What Can Be Expected:
After your treatment, please be aware and observe the following:
Immediately after your treatment, you will look as though you have a moderate to severe sunburn and your skin may feel warm and tighter than usual. This is normal and will subside after 1 to 2 hours and will normally diminish within the same day or 24 hours. You may see slight redness after 24 hours but only in minimal areas or spots.
Your practitioner will discuss post-procedure skincare following the treatment to help soothe, calm, and protect the skin. Continue to treat the skin gently for 3 days. Normal skincare can be resumed again after Day 3.
Sensicure cream as a Glide medium
Sensicure cream – to reduce erythema and reddening
(Good support to reduce PIH and Erythema Risk)
IMMEDIATE POST PROCEDURE
Sensicure Cream (only if you feel it necessary to further reduce surface irritation)
Apply Tebiskin UV Sooth (Uva and UVB) spf 50 (use for 3-7 days AM)
After the Treatment:
Be certain to adhere to the following post-treatment instructions:
CLEAN – Use a gentle cleanse and tepid water to cleanse the face for the following 72 hours and gently dry the treated skin. Always make sure that your hands are clean when touching the treated area.
We would recommend using Tebiskin Sooth Clean as it is a cleanser. It is used on sensitive and hyperactive skin and has a soothing agent in it so is a great product to use after any treatment.
HEAL – Serum antioxidants are recommended post-treatment as the properties are ideal to help heal the skin. These products can help soothe the skin and lessen irritation.
We would recommend using Tebiskin EGF as this is a cream suitable for improving the skin after any procedure, especially when there is a loss of the biochemical properties of the skin.
HYDRATE – Following your Derma FNS treatment, your skin may feel drier than normal. Hyaluronic Acid is an ideal ingredient to hydrate and restore the skin back to perfect balance.
We would recommend using Tebiskin HYAL as it helps increase the hydration for the skin and the elasticity and tone of the skin.
PROTECT – Immediately after the procedure, apply a broad spectrum UVA/UVB sunscreen with an SPF 25 or greater. A chemical-free sunscreen is highly recommended.
We would recommend Tebiskin UV-Sooth as it has strong soothing agents in it and helps protect the skin after any procedure, especially sensitive and hyperactive skin.
MAKEUP – It is recommended that makeup should not be applied for 24 hours after the procedure. Do not apply any makeup with a makeup brush, especially if it is not clean.
RECOVERY AND REJUVENATION
4 weeks post procedure
The products recommended using: Tebiskin HYAL and Tebiskin EGF (24-48 hours post treatment)
What to Avoid:
To ensure the proper healing environment, be certain to observe the following:
For at least 3 days post treatment, do NOT use any Alpha Hydroxy Acids, Beta Hydroxy Acid, Retinol (Vitamin A), Vitamin C (in a low pH formula) or anything perceived as ‘active’ skincare.
Avoid intentional and direct sunlight for 24 hours. No tanning beds.
Do not go swimming for at least 24 hours post-treatment.
No exercising or strenuous activity for the first 24 hours post-treatment. Sweating and gym environments are harmful, rife with bacteria, and may cause adverse reactions.