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ck aesthetics

AESPLLA CONSENT FORM

Date of birth
Please complete the following medical questionnaire:
Have you ever suffered with?
Are you taking any steroids, aspirin or anticoagulant (i.e. warfarin, apixaban, rivaroxaban etc.)?
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 untreated epilepsy?
Yes
No
Do you tend to develop hypertrophic scarring?
Yes
No

If you have said yes to any of the above, your Practitioner may ask you for further details.


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


aesPlla@ is a sterile suspension of poly-L-lactic acid, which is a biocompatible (does not harm the body) and biodegradable (broken down naturally by the body) synthetic polymer from the alpha hydroxy acid (AHA) family (organic acids). Poly-L-lactic acid has been used medically for many years in dissolvable stitches.


aesPlla®️ is injected into the deep layers of the face to help correct skin depressions, such as creases, wrinkles, folds, skin ageing, and facial lipoatrophy (loss of fat).


The effect of the treatment with aesPlla®️ may last up to 3 years. Most areas of treatment will require multiple treatments, usually 3 sessions at a minimum of 4-week intervals, for optimal correction. Because individual response to aesPlla®️ may vary, the exact number of treatment sessions required cannot be predicted with complete accuracy. Additionally, in order to maintain the desired degree of correction, intermittent 'touch-up' treatments may be necessary.


Risks/Discomfort:

Swelling, redness, pain, itching, discolouration, and tenderness at the injection site. These typically resolve spontaneously, usually within 1 to 15 days after injection.

Because aesPlla®️ is injected in a solution containing water, there will be some initial swelling which will be noticeable for at least several hours and perhaps as long as several days. This effect is temporary and does not affect or reflect the long-term tissue response.

Induration, or a feeling of fullness or thickness, can be felt in the injection areas. This is a normal response of the treated tissue to the process of inflammation and new collagen formation. Simply massaging the treated areas gently 5 times per day, for 5 minutes, for 5 days after the injection can help minimise induration.

One possible delayed side effect are small bumps under the skin which may or may not be visible and may be felt in the areas of treatment. These nodules tend to happen within the first 6 to 12 months after the treatment and are usually as a result of collagen over-production. They usually do not require treatment, are not painful and usually do not have any symptoms.

Visible bumps may occur in rare instances, and they may be associated with redness, tenderness, and skin discolouration. These bumps, which are known as granuloma, may or may not require treatment, including, but not limited to, injection, freezing or excision.

Other rarely reported adverse events include: injection site abscess, allergic reaction, skin hypertrophy (exaggerated increase of collagen and tissue elasticity) and/or atrophy (reduction of collagen and tissue elasticity), malaise, fatigue and swelling (oedema).

Consent:

- I voluntarily request treatment using aesPlla®️. My questions regarding such treatment, alternatives, complications, and risk have been answered by the treating practitioner.

- The information which I have been given has been clear to me and I understand the risks and complications of the treatment. I also understand that no specific aesthetic outcome can be guaranteed, and due to the subjective nature of aesthetic treatments I accept this fact.

- My questions have been fully and completely answered for me and I have read this document and understand its contents.


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


Date and time
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