Client Informed Consent Form

Hyaluronic Acid (HA) fillers are sterile gels consisting of non-animal stabilized hyaluronic acid for injections into the skin to correct facial lines, wrinkles and folds, for lip enhancement and for shaping facial contours.

Occasionally, these fillers need to be dissolved when the aesthetic treatment has not produced the desired outcome or there is a possibility of vascular occlusion or impending necrosis (tissue death which could lead to the compromise of healthy tissue.

Hyaluronidase (hyaluronidase 1500 units) has an off-license use in aesthetic medicine and except in the case of emergency administration requires the patient to undergo a skin patch test at least twenty minutes prior to the procedure being undertaken. The skin patch test is carried out by injecting Hyaluronidase into the subcutaneous tissue of the forearm and observed for signs of reaction (i.e. hives or welts). If a positive test result is observed, treatment with Hyaluronidase cannot be carried out. Erythema or redness and slight vasodilation may be expected.

Hyaluronidase is an enzyme which breaks down hyaluronic acid fillers.  I understand that there will be loss of volume and there can be some skin laxity which in itself may not provide a good aesthetic result. Although some of the effects can be immediate, I understand that it can take up to 14 days for the final results to be seen and the treatment may need to be repeated.

Hyaluronidase administration can result in anaphylaxis and I understand this and have been given full counseling and the opportunity to discuss the treatment with Hyaluronidase, conservative treatment options or leaving the dermal filler to breakdown naturally which may take several months dependent on the type of filler used and the areatreated.

The use of and the indications for the administration of Hyaluronidase have been explained to me by Tara Cutrone FNP-BC and I have had the opportunity to have all questions answered to my satisfaction. After the treatment some other common injection related reactions might occur. These reactions include redness, swelling, pain, itching, bruising and tenderness at the injection site. They have generally been described as mild to moderate and typically resolve spontaneously a few days after injection. Bruising may occasionally be more significant.

I acknowledge that I will have to remain at the clinic for thirty minutes after the procedure so that I can be observed by the medical staff and that I may need to return to the clinic 2-3 weeks aftertreatment to assess if further Hyaluronidase is to be administered.

I have answered the questions regarding my medical history to the best of my knowledge.

I have also received the aftercare information and its contents have been explained to me and I will follow the advice given.

I consent to being treated with Hyaluronidase (HA Filler dissolver).