Consent Information
Anti Wrinkle Injections Consent:
Anti Wrinkle injections involve a series of small injections in order to weaken/relax the chosen muscles.
Weakening of the injected muscles begins to be apparent after 3-5 days with the peak effect being reached after 14 days. This is when you will be due to come back for a review.
If you have Dynamic Wrinkles which are wrinkles that appear in motion like when Frowning but are not visible when resting then these will be completely gone after your review / top up and you will no longer be able to Frown therefore will not be able to create those wrinkles.
If you have Static Wrinkles which means your wrinkles are present at rest it is extremely important to understand that these wrinkles will not disappear. Anti Wrinkle Injections are a muscle relaxant and preventative. They do not fill the wrinkles or cause them to disappear if they are already present without movement. That being said over time with regular treatments they will soften.
Results can last 3-6 months depending on dosage, the area treated and lifestyle factors such as sun exposure, smoking and excessive exercise. The procedure can / should be repeated after 3 months.
Bruising at the Injection Point:
It is important to know bruising at the injection point can happen.
It is rare that you will bruise at each and every injection point but it is important to know i can happen.
This doesn't mean anything has gone wrong or it has been administered incorrectly, it just means the end of the needle has nicked a blood vessel below the surface lower than the eye can see, which has caused the blood to come up to the surface and form a small bruise.
DO:
-Apply a cold compress to the bruise, but be sure to not press down hard
-Apply Arnica Gel
-Be Patient, the bruise will go
DON'T
-Massage the area, this will cause the bruise to spread
I am aware of the following risks/complications that may occur:
- Mild to moderate discomfort or pain
- Slight redness or swelling
- Headaches
- Muscle Activity Disorder
- Drooping Eyelids
- Inflammation
- Blurred Vision
- Fainting
- Muscle Twitching
- Bleeding
- Bruising/Swelling
- Risk of Infection
- Unsatisfactory Outcome/Temporary loss of function of nearby muscles.
In the event of an adverse reaction medical help should be sought immediately.
I confirm I do not suffer with any of the Contra-indications associated with Botox Anti Wrinkle Injections:
- Coldsores (herpes virus)
- Granulomas
- Spots/acne at the injection sites (mainly lips)
- Active Infections (skin)
- Allergy/Hypersensitivity to Botulinum Toxin or its constituents (Lactose, Sodium succinate, Human Albumin).
- Scar tissue
- Pregnancy
- Breastfeeding mothers
- Body Dysmorphia
- Unrealistic Expectations
- Blood thinning medication
- Blepharoptosis (Droopy Eyelid)
- Eyebrow Ptsosis (Droopy Eyebrow)
- Epiphora (Excessive Tearing)
- Xerophthalmia (Dry Eyes)
- Lagophthalmos (Incomplete Eye Closure)
- Ectropion of Lower Eyelid (Eyelid Margin Eversion)
- Diplopia (Double Vision)
- Impaired Blink Relfex
- Globe Trauma (Orbital Trauma/Blunt Trauma To Eye)
- Photophobia (Sensitivity to Light)
- Infraorbital Festooning (Worsening of Eyebags)
- Cheek Flaccidity
- Dysphagia (Difficulty Swalling)
I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure.
I consent and authorise Paige Edmonds to perform one or more Botox Anti Wrinkle treatments on me. I certify that I have read this entire informed consent and I understand and agree to the information provided in the form. My questions regarding the procedure have been answered satisfactorily.
I hereby release Paige Edmonds from all liabilities associated with this procedure. This consent is valid for all of my Botox Anti Wrinkle treatments in the future as well.
Chemical Peel Consent:
A chemical peel can be used to diminish the appearance of fine lines and wrinkles, improve texture/tone, reduce pore size, increase hydration and moisture retention, give skin a smoother appearance and diminish the appearance of hyperpigmentation. Layers of product are applied based on your unique skin composition and needs. Multiple treatments are required in order to obtain optimal results spaced 2-6 weeks apart. Due to variables such as age, condition of your skin, sun damage, smoking, skin care products, climate, life-style, and general health, you acknowledge that there are no guarantees, warranties or assurances that you will be satisfied with your results.
Contraindications:
1. Herpes Simplex (cold sores or fever blisters)
An anti-viral medication may be necessary prior to treatment
2. Dermatitis
3. Open skin lesions
4. Uncontrolled diabetes
5. Extensive sun or tanning 3 days prior and 3 days post treatment
6. Accutane in the past 6 months to 1 year
7. Prescription topical retinol products in the past 2 weeks
8. Waxing of area to be treated in the past 7 days
9. Skin must be healthy and intact
10. An allergy to aspirin
11. Active Infections (skin)
12. Allergy/Hypersensitivity to certain skincare ingredients / topicals
13. Blood thinning medication
I am aware of the following risks/complications that may occur:
- Mild to moderate discomfort or pain
- Slight redness or swelling
- Sun sensitivity
- Skin sensitivity
- Pigment changes
- Scarring
- Allergic reaction
- Bacterial infection
- Peeling/shedding/flaking
I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure.
I consent and authorise Paige Edmonds to perform one or more chemical peels on me. I certify that I have read this entire informed consent and I understand and agree to the information provided in the form. My questions regarding the procedure have been answered satisfactorily.
I hereby release Paige Edmonds from all liabilities associated with this procedure. This consent is valid for all of my chemical peel treatments in the future as well.
Dermaplaning Consent:
Dermaplaning is a method of exfoliation that consists of using a surgical scalpel to gently scrape off the top layer of dulling dead skin cells in order to reveal a smoother, brighter complexion. Dermaplaning removes all the dead skin cells and also the vellus facial hair, leaving the surface very smooth allowing for greater penetration of skincare products. It also creates a flawless canvas for makeup to glide on smoothly. Multiple treatments are required in order to obtain optimal results spaced 4-6 weeks apart. Due to variables such as age, condition of your skin, sun damage, smoking, skin care products, climate, life-style, and general health, you acknowledge that there are no guarantees, warranties or assurances that you will be satisfied with your results.
Contraindications:
1. Herpes Simplex (cold sores or fever blisters)
An anti-viral medication may be necessary prior to treatment
2. Dermatitis
3. Open skin lesions
4. Uncontrolled diabetes
5. Extensive sun or tanning 3 days prior and 3 days post treatment
6. Accutane in the past 6 months to 1 year
7. Prescription topical retinol products in the past 2 weeks
8. Waxing of area to be treated in the past 7 days
9. Skin must be healthy and intact
10. An allergy to aspirin
11. Active Infections (skin)
12. Allergy/Hypersensitivity to certain skincare ingredients / topicals
13. Blood thinning medication
I am aware of the following risks/complications that may occur:
- Slight redness
- Sun sensitivity
- Skin sensitivity
- Pigment changes
- Breakouts
- Irritation
- Allergic reaction
- Bacterial infection
I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure.
I consent and authorise Paige Edmonds to perform one or more Dermaplaning treatments on me. I certify that I have read this entire informed consent and I understand and agree to the information provided in the form. My questions regarding the procedure have been answered satisfactorily.
I hereby release Paige Edmonds from all liabilities associated with this procedure. This consent is valid for all of my Dermaplaning treatments in the future as well.
Hydrofacial Consent:
The Hydrofacial provides hydration, oxygenation, anti-ageing, brightening, skin tightening and improves congestion, resulting in a glowing, brighter, more youthful-looking skin.
During treatment, you will experience varying sensations depending on the technologies that are used. However, the overall feeling is very relaxing, cooling and completely pain-free. The skin lifting technology may trigger slight twitching due to muscle contractions caused by the treatment, but this is normal and does not cause any discomfort.
Multiple treatments are required in order to obtain optimal results spaced 2-6 weeks apart. Due to variables such as age, condition of your skin, sun damage, smoking, skin care products, climate, life-style, and general health, you acknowledge that there are no guarantees, warranties or assurances that you will be satisfied with your results.
Contraindications:
1. Herpes Simplex (cold sores or fever blisters)
An anti-viral medication may be necessary prior to treatment
2. Dermatitis
3. Open skin lesions
4. Uncontrolled diabetes
5. Extensive sun or tanning 3 days prior and 3 days post treatment
6. Accutane in the past 6 months to 1 year
7. Prescription topical retinol products in the past 2 weeks
8. Waxing of area to be treated in the past 7 days
9. Skin must be healthy and intact
10. An allergy to aspirin
11. Active Infections (skin)
12. Allergy/Hypersensitivity to certain skincare ingredients / topicals
13. Blood thinning medication
I am aware of the following risks/complications that may occur:
- Mild discomfort or pain
- Slight redness or swelling
- Sun sensitivity
- Skin sensitivity
- Pigment changes
- Allergic reaction
- Bacterial infection
- Peeling/shedding/flaking
- Erythema
10 technologies within the Hydrofacial treatment:
1) HYDROPEEL 1
AHA is used to dissolve keratin and deep cleanse pores to remove blackheads and smooth the skins texture.
2) HYDROPEEL 2
BHA is used to remove comedones, sebum and to deep cleanse inner pores. More so used on heavily congested areas i.e. Nose, Chin, Cheeks, T Zone. It also has anti-inflammatory and anti-bacterial properties.
3) VIBRATION CLEANSE
Creates ‘the Bohr effect’, allowing oxygen to be drawn into the skin. The active ingredients used are Kojic Acid and Retinol which result in a hydrating and brightening effect.
4) RADIO FREQUENCY – SKIN TIGHTENING
Radio Frequency uses low energy radiation to heat the deep layer of your skin called the dermis. This heat stimulates the production of collagen to help improve signs of wrinkles and sagging skin.
5) ELECTRO ION – SKIN LIFTING / SCULPTING
This treatment uses electroporation to increase the absorbency of the cell for product penetration. With patented muscle stimulation it deeply activates and elevates your facial muscles, giving you the appearance of a fuller, more youthful face in just 10 minutes.
6) HYDROPEEL 3
Galactomyces Ferment Filtrate which gives deep hydration and nourishment to the skin which provides elasticity and brightening.
7) FIRE – HOT PLATE
The ‘fire’ represents the heat element during treatment to open the pores, increase blood supply, and aid product infusion.
8) ULTRASOUND HYDRATION
Ultrasound technology is used for product infusion. A Hyaluronic Mask is placed on the face and the ultrasound technology is used for 10 mins for maximum infusion.
9) OXYGENATION SPRAY
This spray creates a venturi effect, breaking down the molecules within the product to encourage skin hydration. Oxygen helps to improve blood circulation to the face, which can help skin look bright and plump.
10) ICE – COLD PLATE
Ice Therapy uses cooling technology, chilling the skin down to 5 ̊C to decrease the bloody supply, giving a tightening effect, and sealing in the infused products. This also helps to reduce any erythema following treatment.
I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure.
I consent and authorise Paige Edmonds to use all 10 technologies that make up the Hydrofacial treatment on me. I certify that I have read this entire informed consent and I understand and agree to the information provided in the form. My questions regarding the procedure have been answered satisfactorily.
I hereby release Paige Edmonds from all liabilities associated with this procedure. This consent is valid for all of my Hydrofacial treatments and all technologies in the future as well.
Microneedling Consent:
Microneedling is typically used for skin rejuvenation, scar repair and hair loss. The treatment uses a medical device that creates controlled micro-surgical needle punctures of the skin. The depth of the needles are based on your unique skin composition and needs. Multiple treatments are required in order to obtain optimal results spaced 4-6 weeks apart. Due to variables such as age, condition of your skin, sun damage, smoking, skin care products, climate, life-style, and general health, you acknowledge that there are no guarantees, warranties or assurances that you will be satisfied with your results.
Although the majority of patients do not experience any complications with Microneedling, it is important you understand that risks do exist. The Microneedling procedure is minimally invasive and uses a set of microneedles to inflict multiple, tiny, punctures/lacerations to the outermost layer of the skin.
I am aware of the following risks/complications that may occur:
- Mild to moderate discomfort or pain
- Slight redness or swelling
- Sun sensitivity
- Skin sensitivity
- Pigment changes
- Scarring
- Allergic reaction
- Bacterial infection
- Minor peeling/shedding/flaking
I am also aware there is a risk of more serious side effects, including:
Possible scarring. Microneedling isn’t a good idea for people who are prone to keloid scarring. Anyone can get a keloid scar, but they're more common in people with darker skin, such as people from Africa and African-Caribbean and south Indian communities.
Unfortunately unless you have had surgery in the past or a deep cut where a scar has formed you will not know whether you are/are not prone to keloid scarring. Which is why it is important to know that there is a risk of this with Microneedling.
Infection. Microneedling creates tiny holes in the skin, which could let germs enter. But the risk of infection is very low. If you’re healthy, an infection from Microneedling is unlikely.
Skin Pigment Changes. Microneedling may worsen dark spots if your skin scars or becomes inflamed easily. If this is the case, Microneedling may cause more inflammation. Following this, your body will send white blood cells to fight off bacteria and infection. This can trigger the production of more melanin, which can then form dark spots or worsen those that are already there.
Granulomatous Dermatitis. Microneedling has been reported to cause Granulomatous Dermatitis, but it is rare.
If you notice small red lumps / circles appear on your skin following your Microneedling session I would contact your GP and arrange a face to face appointment with them. They will be able to give a prescription strength treatment to help heal Granulomatous Dermatitis at a much quicker rate.
I confirm I do not suffer with any of the Contra-indications associated with Microneedling:
- Herpes Simplex (cold sores or fever blisters)
An anti-viral medication may be necessary prior to treatment
2. Dermatitis
3. Open skin lesions
4. Uncontrolled diabetes
5. Extensive sun or tanning 3 days prior and 3 days post treatment
6. Accutane in the past 6 months to 1 year
7. Prescription topical retinol products in the past 2 weeks
8. Waxing of area to be treated in the past 7 days
9. Skin must be healthy and intact
10. An allergy to aspirin
11. Active Infections (skin)
12. Allergy/Hypersensitivity to certain skincare ingredients / topicals
13. Granulomas
14. Prone to Keloid scarring
I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure.
I consent and authorise Paige Edmonds to perform one or more Microneedling treatments on me. I certify that I have read this entire informed consent and I understand and agree to the information provided in the form. My questions regarding the procedure have been answered satisfactorily.
I hereby release Paige Edmonds from all liabilities associated with this procedure. This consent is valid for all of my Microneedling treatments in the future as well.
LED Therapy Consent:
LED light therapy is a popular non invasive skin treatment for acne, sun damage, wounds, and other skin problems.
The treatment uses varying wavelengths of light to trigger the skin’s natural healing processes to repair the skin. Several treatments are necessary to see results.
LED is safe, non-thermal, nontoxic and non-invasive, and to date no side effects have been reported in published literature. In the 20 years that LED has been used in the medical and beauty industry, there have been no reported incidents of adverse reactions or damage caused by LED therapy.
Something to bare in mind is that you may be more sensitive to light if you have any of the below or are taking any of the below medications;
-Light Sensitive Medication
-Antibiotics
-Topical Retinol/Retinal
-Roaccutane / Isotretinoin
-Epilepsy
-Pregnancy
I consent and authorise Paige Edmonds to perform one or more LED therapy sessions on me. I certify that I have read this entire informed consent and I understand and agree to the information provided in the form. My questions regarding the procedure have been answered satisfactorily.
I hereby release Paige Edmonds from all liabilities associated with this procedure. This consent is valid for all of my LED therapy sessions in the future as well.
PRP Consent:
Platelet Rich Plasma, also known as PRP, is derived from the patient’s own blood in the following manner. A fraction of blood (60cc) is drawn from the individual patient into a syringe. This is a relatively small amount compared to blood donation. The blood is spun in a special centrifuge to separate its components (Red Blood Cells, Platelet Rich Plasma, Platelet Poor Plasma and White Blood Cells).
The Platelet Rich Plasma containing monocytes and various plasma proteins are collected into a syringe. A sterile Calcium Chloride 10% and sterile Bicarbonate 8.4% solution is added in 5% volume to the syringe containing PRP. Calcium Chloride and Bicarbonate both work to activate the platelets, thus leading to liberation of growth factors and healing elements. The activated platelets are then injected with in the next few minutes as a medical intervention. As the platelets organize in the clot, they release enzymes to promote healing and tissue responses including attracting stem cells and growth factors to repair damaged tissue and cause regeneration and rejuvenation.
The full procedure may take between 15-45 minutes. Often 2-3 treatments are advised, however, more or less may be necessary for some individuals. It is often recommended that treatments be done once a year after the initial group of treatments to continue regeneration and maintain or enhance the results.
BENEFITS of PRP:
PRP is autologous (using your own blood) therefore eliminating allergy potential. PRP has been shown to have tissue regenerating effects. Other benefits include: minimal down time, safe with minimal risk, short recovery time, and no general anesthesia is required.
CONTRAINDICATIONS:
PRP use is safe for most individuals between the ages of 18- 80. There are very few contraindications, however, patients with the following conditions are not candidates:
- Pregnancy or Lactation
2. Acute and Chronic Infections
3. Skin diseases (i.e. SLE, porphyria, allergies)
4. Cancer
5. Chemotherapy treatments
6. Severe metabolic and systemic disorders
7. Abnormal platelet function (blood disorders, i.e. Hemodynamic Instability, Hypofibrinogenemia, Critical Thrombocytopenia)
8. Chronic Liver Disease
9. Anti-coagulation therapy (Coumadin, Warfarin, Plavix, Aspirin, Lovenox)
10. Underlying Sepsis
11. Systemic use of corticosteroids within two weeks of procedure
RISKS & COMPLICATIONS:
Some of the Potential Side Effects of Platelet Rich Plasma include:
1. Pain at the injection site
2. Bleeding, Bruising and/or Infection as with any type of injection
3. Short lasting pinkness/redness (flushing) of the skin
4. Allergic reaction to the solution, an/or topical anaesthetic
5. Injury to a nerve and/or muscle as with any type of injection
6. Itching and swelling at the injection site(s)
7. Minimal or no effect from the treatment
Additional Procedure Specific Risks in addition to those stated above:
SCALP PRP:
I acknowledge that the following is a risk of Scalp PRP:
• No effect at all
• Worsening Hair Loss
• Severe head ache
• Injection site Infection / hematoma
• Swelling that may extend into the tissue around the eyes (may last several days)
FACIAL PRP:
I acknowledge that the following is a risk of Facial PRP:
• Injection site Infection / Hematoma
• Redness, swelling and discoloration
• Swelling and redness lasting up to 72 hours is possible
RESULTS:
I understand that due to the natural variation in quality of Platelet rich plasma, results will vary between individuals. I understand that although I may see a change after my first treatment; I may require multiple sessions to obtain my desired outcome. It is recommended that once treatment goals are accomplished, an annual PRP procedure is likely necessary to maintain results.
My consent and authorization for this elective procedure is strictly voluntary. By signing this informed consent form, I hereby grant authority to the physician/practitioner to perform Platelet Rich Plasma “aka" PRP to area(s) discussed during our consultation, for the purpose of rejuvenation and regeneration of affected tissue.
I have read this informed consent and certify I understand its contents in full. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I agree to adhere to all safety precautions and instructions after the treatment. I have been instructed in and understand post treatment instructions and have been given a written copy of them.
I understand that medicine is not an exact science and acknowledge that no guarantee has been given or implied by anyone as to the results that may be obtained by this treatment. I also understand this procedure is "elective" and not covered by insurance and that payment is my responsibility. Payment in full for all treatments is required at the time of service and is non-refundable.
I hereby give my voluntary consent to this PRP procedure and release Paige Edmonds from liability associated with the procedure. I certify that l am a competent adult of at least 18 years of age and am not under the influence of alcohol or drugs. This consent form shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns. I agree that if I should have any questions or concerns regarding my treatment, I will notify this office and/or provider immediately so that timely follow-up and intervention can be provided.
Profhilo Consent:
Profhilo® is an exclusive skin remodelling treatment designed for individuals with ageing skin that is lacking volume and elasticity. Profhilo® stimulates the production of collagen and elastin through the slow release of Hyaluronic Acid (HA) and in doing so significantly improves the appearance of fine lines and wrinkles as well as increasing hydration and firmness across the face resulting in an overall rejuvenated appearance. Profhilo is an injectable hyaluronic acid based product for treating skin laxity. With one of the highest concentrations of hyaluronic acid on the market, it is not only boosting and hydrating the skin, but also remodelling the ageing and sagging of tissue.
After injection into the skin, Profhilo starts to work immediately.
Its unique structure allows it to flow freely through the subcutaneous tissue and dermis in the target areas, creating volume evenly over the following 24 to 48 hours.
This gives Profhilo a significant advantage over other filler treatments, as the product doesn’t form into lumps or nodules that need to be massaged to help create the desired result.
The product remains in the skin for about 28 days, in which time it continues to stimulate the production collagen and elastin by slowly releasing the HA.
This creates both a ‘dermal scaffold’ that tightens and lifts the skin, while also boosting skin tissue quality through HA’s hydrating and stimulating action.
The improvements to the firmness, elasticity and overall quality of your skin should last up to 6 months.
Bruising at the Injection Point:
It is important to know bruising at the injection point can happen.
It is rare that you will bruise at each and every injection point but it is important to know i can happen.
This doesn't mean anything has gone wrong or it has been administered incorrectly, it just means the end of the needle has nicked a blood vessel below the surface lower than the eye can see, which has caused the blood to come up to the surface and form a small bruise.
DO:
-Apply a cold compress to the bruise, but be sure to not press down hard
-Apply Arnica Gel
-Be Patient, the bruise will go
DON'T
-Massage the area, this will cause the bruise to spread
I am aware of the following risks/complications that may occur:
- Mild to moderate discomfort or pain
- Slight redness or swelling
- Inflammation
- Fainting
- Bleeding
- Bruising/Swelling
- Risk of Infection
- Unsatisfactory Outcome/Temporary loss of function of nearby muscles.
I confirm I do not suffer with any of the Contra-indications associated with Profhilo Injections:
- Coldsores (herpes virus)
- Granulomas
- Spots/acne at the injection sites
- Active Infections (skin)
- Allergy/Hypersensitivity to Hyaluronic Acid
- Scar tissue
- Pregnancy
- Breastfeeding mothers
- Body Dysmorphia
- Unrealistic Expectations
- Blood thinning medication
I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure.
I consent and authorise Paige Edmonds to perform one or more Profhilo treatments on me. I certify that I have read this entire informed consent and I understand and agree to the information provided in the form. My questions regarding the procedure have been answered satisfactorily.
I hereby release Paige Edmonds from all liabilities associated with this procedure. This consent is valid for all of my Profhilo treatments in the future as well.
Sunekos Consent:
The Sunekos regeneration system for dermal biogenesis is a non-invasive medical treatment, consisting in injecting, through a fine needle or a cannula. The procedure is relatively painless and a topical anaesthetic can be applied prior to treatment with Sunekos. The treatment normally lasts about 15-20 minutes and at the end you can immediately resume normal activities. The intradermal plant of natural chemically unmodified high and low molecular weight hyaluronic acid, plus amino acids of collagen and elastin (in Sunekos 200 and 1200) is one of the methods used for rejuvenation Hyaluronic acid and the amino acids of collagen and elastin are substances already present in the human body, they are reabsorbed and are used for the synthesis of a new dermal matrix. The duration of the effect depends on multiple factors (individual characteristics, sun exposure, skin treatments, etc.)
The regeneration system for dermal biogenesis is a treatment indicated both for young, still elastic and vital skin, to slow down the physiological aging process, and for mature skin to reduce the signs of aging, reactivating cellular functionality. Sunekos 200 or 1200 have not had any reportable allergic reactions reported to date so its use does not require preliminary tests.
However, we advise that if you were to have a reaction, you would need to inform your practitioner
Bruising at the Injection Point:
It is important to know bruising at the injection point can happen.
It is rare that you will bruise at each and every injection point but it is important to know i can happen.
This doesn't mean anything has gone wrong or it has been administered incorrectly, it just means the end of the needle has nicked a blood vessel below the surface lower than the eye can see, which has caused the blood to come up to the surface and form a small bruise.
DO:
-Apply a cold compress to the bruise, but be sure to not press down hard
-Apply Arnica Gel
-Be Patient, the bruise will go
DON'T
-Massage the area, this will cause the bruise to spread
I am aware of the following risks/complications that may occur:
- Mild to moderate discomfort or pain
- Slight redness or swelling
- Inflammation
- Fainting
- Bleeding
- Bruising/Swelling
- Risk of Infection
- Unsatisfactory Outcome/Temporary loss of function of nearby muscles.
I confirm I do not suffer with any of the Contra-indications associated with Sunekos Injections:
- Coldsores (herpes virus)
- Granulomas
- Spots/acne at the injection sites
- Active Infections (skin)
- Allergy/Hypersensitivity to Hyaluronic Acid
- Scar tissue
- Pregnancy
- Breastfeeding mothers
- Body Dysmorphia
- Unrealistic Expectations
- Blood thinning medication
I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure.
I consent and authorise Paige Edmonds to perform one or more Sunekos treatments on me. I certify that I have read this entire informed consent and I understand and agree to the information provided in the form. My questions regarding the procedure have been answered satisfactorily.
I hereby release Paige Edmonds from all liabilities associated with this procedure. This consent is valid for all of my Sunekos treatments in the future as well.
Vitamin Injections Consent:
An intramuscular injection is a technique used to deliver a medication deep into the muscles. This allows the medication to be absorbed into the bloodstream quickly.
Vitamin Injections common side effects include but are not limited to:
Mild diarrhea, upset stomach, nausea, a feeling of pain and a warm sensation at the site of the injection, a feeling, or a sense, of being swollen over the entire body, headache and joint pain.
If any of these side effects become severe or troublesome I will contact my physician immediately.
I understand that although rare Vitamin injections can result in serious side effects. Although this is a relatively rare occurrence, anyone taking Vitamin injections should be aware of the possibility.
Uncommon side effects are much more serious than the common side effects of Vitamin injections, and such side effects should be reported to a physician to be evaluated for seriousness.
Uncommon and dangerous side effects include:
• headache
• nausea
• diarrhea
• bloating
• constipation
• indigestion or heartburn
• abnormal bleeding
• gastrointestinal hyperactivity
• chest pain
• flushed face
• chills
• fever
• upset stomach
• kidney stones
• fingernail weakening
• hair loss
• rapid heartbeat
• heart palpitations
• restlessness
• muscle cramps and weakness
• dizziness
I understand the possibility of having an allergic reaction to any of the ingredients found within the Vitamin injection is quite plausible and that I should communicate with my Physician if I have any known allergic reactions to foods, dyes, preservatives, or any other substances. If I experience any of these following signs of allergic reactions I should immediately consult my primary health care Physician and discontinue further use of the product.
Signs of allergic reactions include, but not limited to:
• Itching of skin
• Hives
• Rashes
• Wheezing
• Difficulty breathing
• Swelling of mouth or throat
When medications are taken in conjunction with the Vitamin Injection, drug interactions could occur. These interactions can either increase your risk of bleeding or block the absorption of the Vitamins into the body. These medications at the time of your injection should either be discontinued or be consulted with by a Physician.
Some of the medications that may cause drug interactions include, but are not limited to:
-
• Heparin (Fragmin, Lovenox, Innohep…ect.)
• Antithrombin (A Tryn, Thrombate III)
• Argatroban
• Aspirin
• Ibuprofen
• Dipyridamole (Persantine)
• Bivalirudin (Angiomax)
• Clopidogrel (Plavix) • Warfarin (Coumadin, Jantoven)
• Nonsteroidal anti-inflammatory drugs (Ibuprofen,…etc.)
Before starting the Vitamin injections I will make sure to tell my Physician if I am pregnant, lactating or have any of the following conditions.
-
• Leber’s Disease
• Kidney disease
• History of Kidney stones
• Liver disease
• Hormonal disease
• Cardiovascular disease
• History of ulcers
• History of gastrointestinal problems
• Bipolar disorder (manic depression)
• Attention Deficit Hyperactivity Disorder (ADHD)
• Muscular Dystrophy
• Elliptic seizures
• Hypoglycemia
• Schizophrenia
• Benign prostatic hypertrophy (BPH)
• Acetaminophen poisoning
• Hypertension (high blood pressure)
• History of seizures
• Under-active thyroid (hypothyroidism)
• Osteoporosis
• Receiving treatment or taking any medication that might “thin” the blood
• Receiving treatment or taking medication that has an effect on bone marrow
• An infection
• Iron deficiency
• Folic acid deficiency
• Dependent on intravenous nutrition (TPN) or liquid nutrition products for food
• Diabetes, mellitus, or high blood sugar levels
• An unusual or allergic reaction other medicines, foods, dyes, or preservatives
I understand that certain herbal products, vitamins, minerals, nutritional supplements, prescription and non prescription medications may result in side effects when they interact with the Vitamin Injection.
Bruising at the Injection Point:
It is important to know bruising at the injection point can happen.
DO:
-Apply a cold compress to the bruise, but be sure to not press down hard
-Apply Arnica Gel
-Be Patient, the bruise will go
DON'T
-Massage the area, this will cause the bruise to spread
I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure.
I consent and authorise Paige Edmonds to perform one or more Vitamin Booster treatments on me. I certify that I have read this entire informed consent and I understand and agree to the information provided in the form. My questions regarding the procedure have been answered satisfactorily.
I hereby release Paige Edmonds from all liabilities associated with this procedure. This consent is valid for all of my Vitamin Booster treatments in the future as well.
Cryopen Consent:
Cryopen is the latest technology for cryotherapy (icy cold temperatures). By using nitrous oxide gas (N2O) freezing down to -89 degrees, we can treat benign lesions on the skin’s surface with pinpoint accuracy.
By using a temperature -89 degrees C, the Cryopen enables the skin to freeze to -45 degree. This causes the liquid inside the lesion’s cell to become shards of ice, and the cell membrane to rupture, thus destroying the cells. This is an extremely fast process that does not allow the body to protect itself during the treatment time; ensuring results.
A wide variety of benign lesions can be treated with cryotherapy, but it is most commonly used to remove:
1. Skin Tags
2. Warts/Verrucae’s
3. Milia
4. Pigmentation
5. Cherry Angioma’s
During the procedure the area freezes and turns white. After this white area thaws, a flushing occurs and the area will turn red and a weal will form. Approximately 2 - 4 hours after being frozen the weal may turn into a blister which may last from 3-5 days then begin to form a scab. This scab will fall off on its own in 1-2 weeks. Depending on the extent of the freeze and tissue area, a new scab may form and the process will repeat. The lesion will be completely healed in 4 weeks, again depending on the extent of the freeze and tissue area. This is when you will be due to come back for your second session.
After primary healing occurs, the area will be lighter than surrounding areas due to loss of melanocytes. Melanocytes are very cold sensitive dying at -5 degrees and below.
Although it is best to try and leave the treated area uncovered, a plaster or simple dressing may be applied if it is in an area that may lead to rubbing and aggravation. It is extremely important not to pick at the crust as this may lead to scarring.
Treatment including post-treatment and risks:
- Treatment lasts from 5-25 seconds, lesion dependent.
- Initial slight discomfort, skin will feel as if it has stung by nettles for 10-60 minutes.
- Try not to cover treatment site if possible.
- Swelling will occur round the site for a few hours. This is normal.
- Stinging for 10-60 minutes post treatment. Painkiller may be taken if necessary.
- Scabs may appear a few days after treatment.
- Do not pick, scratch or rub scabs or burst blisters as scarring may occur. Do not take any antihistamine for 48 hours the day before treatment day and 48 hours after. The treatment is partly based on histamine action.
- Lesion will shed after 4 -14 days, but can last over 4 weeks.
- Healing takes up to 4 weeks in most cases.
- Temporary skin colour change (skin darkens) often occurs, but in darker skins may be permanent.
- Use SPF 50 on new skin when lesion has shed. There will be new pink skin underneath. This will gradually re-pigment to your skin’s natural colour.
- If healing is not as expected and redness or pain is present please contact clinic or your Doctor as you may have contracted an infection.
Contra-indications:
- Not suitable for pregnant or breast-feeding women.
- Agammaglobulinemia (inherited cold intolerance, higher risk of infection.
- Cold uticaria. (Hives when cold)
- Concurrent dialysis treatment.
- Collagen vascular disease.
- Autoimmune diseases.
- Rheumatoid arthritis.Temporal Arthritis.
- Scleroderma (cranial arthritis, Giant cell arthritis)Immunosuppression, immunodeficiency disorders. (high infection risk)Multiple myloma (Cancer starting in bone marrow plasma cells)
- Pyoderma Gangrenosum ( ulcerating/necrotic condition, usually found on legs.)Platelet deficiency.Human T-cell Lymphotropic virus III.
- Lymphademoopathy associated virus.
- Form of Creutzfieds Jakob Disease, CJD, TSE, vCJD, nvCJD.
- Dermal fillers under the site to be treated
CryoPen™ cannot be used if you are taking Antihistamines and you would need to have a break from them for 2 or 3 days prior to treatment.
CryoPen™ is not recommended for darker skin types as it will kill the melanocytes in the surrounding area and the skin in that area will become lighter, basically just swapping one concern for another.
PLEASE CONTACT YOUR GP IF THE TREATED AREA IS WEEPING 2 WEEKS FOLLOWING TREATMENT.
I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure.
I consent and authorise Paige Edmonds to perform one or more Cryopen treatments on me. I certify that I have read this entire informed consent and I understand and agree to the information provided in the form. My questions regarding the procedure have been answered satisfactorily.
I hereby release Paige Edmonds from all liabilities associated with this procedure. This consent is valid for all of my Cryopen treatments in the future as well.