Hyalase® Filler Dissolver Consent

This form is not just a formality- it’s a record of your decision to concent 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 check the boxes you have read, understood and discussed as required with your clinician.

What is being injected?

Hyaluronidase is an enzyme that breaks down dermal llers made of hyaluronic acid into small sugars which easily disperse. Risks of the procedure include but may not be limited to:

Risks of injection:*
Reactions:*
Side Effects:*
Treatment Failure:*
Complications from infection:*
Follow-up:*
Dissatisfaction:*
Client Name*
By signing this form, you agree that you have read this form carefully and considered the side effects, risks and uncertainty of the outcome and decided the treatment is still in your best interests. You have discussed all the details of the treatment plan, past treatments and your medical history with your clinician and shared all the information your clinician may need to plan treatment. You agree that the balance of the benets and risks to you overall favour the use of dermal ller. You understand that the initial treatment of side effects and complications is included in the cost of the procedure and therefore no refunds are issued due to any of the above occurring. You understand photographs are taken and stored for 7 years as part of my clinical record:
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