Vitaran form | CK Aesthetics

First name

Last name

Email

Date of birth

Address

Telephone

Please complete the following medical questionnaire:

Are you pregnant or breast feeding?

Have you a history of severe allergy / anaphylaxis?

Are you currently receiving any medical treatment?

If yes to any of the above, please give more details. If no, state 'no'.

Have you previously received any aesthetic treatments (e.g. laser, peels, dermabrasion etc.)? If yes, please give more details.

Have you had any treatment with dermal fillers, absorbable dermal fillers, semi-permanent dermal fillers or botulinum toxin? If yes, which treatment did you receive, what areas were treated and when?

Have you ever suffered with?

Auto-immune disease or any disease affecting the immune system?

Do you have cutaneous (skin) infection or inflammatory problems

Herpes (cold sores)?

Acne?

Do you suffer with an allergic disease, autoimmune disease, sarcoidosis granulomatous pathology or Osler's endocarditis?

Yes

No

Are you taking NSAIDs (e.g. ibuprofen and naproxen), platelet aggregation inhibitors (e.g. asprin and clopidogrel), anticoagulants (e.g. apixaban, rivaroxaban and warfarin) or immunosuppressants?

Yes

No

Do you suffer with hyperpigmentation, hypertrophic scarring or keloid formation?

Yes

No

Do you suffer from acute rheumatic fever or recurrent sore throat?

Yes

No

Do you suffer from any allergies, in particular allergies to hyaluronic acid, amide type local anaesthetics or lidocaine?

Yes

No

Do you suffer from cardiac conduction disorders (heart rhythm problems etc.)? If yes, please provide details. If no, state 'no'.

If you have said yes to any of the above, your Practitioner may ask you for further details. Treatment may be refused if it not considered in your best interest to proceed.

Please read and by typing your name below you agree to the following.

ABOUT

VITARAN is a skin injectable which contains polynucleotide sodium derived from 100% purified fragments of trout DNA. The injectable is administered into areas of the face, neck, décolletage, hands and areas of the body in order to reduce the signs of ageing by improving the appearance of fine lines and wrinkles.

VITARAN has anti-inflammatory properties and activates the skin's production of collagen, elastin and hyaluronic acid, which hydrates the skin. As a result, the skin is rejuvenated, its cell turnover is regulated and its natural barrier is repaired. In addition, VITARAN is capable of facilitating the remodelling of areas of the skin which have high fibrous content, including stretch marks and scars.

A topical anaesthesia, such as numbing cream, can be used in order to reduce the discomfort of the injection(s). Prior to the injection, the treatment site must be washed with an antiseptic cleansing solution.

Multiple injections can be made depending on the treatment site, depth of the wrinkles, skin condition, technique used and desired level of correction.

After the first treatment, additional polynucleotide treatments may be necessary to achieve the desired results. The recommended treatment protocol is 2-3 treatments which should be spaced 3-4 weeks apart.

Following this, a top-up treatment is recommended every 6-12 months depending on skin condition and the desired level of correction.

SIDE-EFFECTS

Treatment using VITARAN can cause some common injection related reactions. The reactions may include, discolouration, inflammation, itching, nodules, and pain, which can occur up to a week after the treatment.

You could experience increased bruising or bleeding at the treatment site if you are taking substances which reduce blood clotting, including aspirin. If reactions continue to occur after a week or any adverse reactions occur you should contact your practitioner. Notably, as with all injections, the treatment carries a risk of infection.

PRECAUTIONS

VITARAN should not be used on patients who: are under 18 years of age, are pregnant, are breastfeeding, have experienced hypersensitivity and have severe allergies, including fish allergies. In addition, polynucleotide injections should not be used on areas with active inflammation or infections (e.g. cysts, hives, pimples and rashes). Most patients are pleased with the results of polynucleotide injections but, like any cosmetic procedure, there is no guarantee that you will be completely satisfied. As a result, you may require additional treatments to achieve optimal results. After the treatment, you should avoid using makeup for up to 12 hours and avoid exposure to UV light, cold and heat (e.g. sauna and steam room) for up to 2 weeks.

CONSENT

• I confirm that the treatment has been explained to me by my practitioner.

• I confirm that my practitioner has received my relevant medical history information.

• I confirm that I have read this consent form and that I understand its contents in full.

• I confirm I have had enough time to consider the information provided to me by my practitioner and feel that I am sufficiently informed to consent to the treatment.

I therefore consent to receiving the treatment by my chosen aesthetic practitioner.

I hereby give my unrestricted informed consent for the procedure. BY TYPING YOUR NAME BELOW YOU AGREE.

Date and time

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Full Name

I agree to all terms and conditions.

FREE CONSULTATION

VITARAN CONSENT FORM