MEDICAL QUESTIONNAIRE PRIOR TO TREATMENT
Subject to medical secrecy.
Your Details
First Name ……………………………………………………………….. Date of Birth ………………………………………………………………
Last Name ……………………………………………………………….. Phone Number ………………………………………………………….
Address …………………………………………………………………… Email Address ……………………………………………………………
Postcode ………………………………………………………………… How did you hear about us? …………………………………….
GP’s name, address and tel: …………………………………. Do you use sunbeds? Yes No
………………………………………………………………………………. Do you smoke? Yes No
……………………………………………………………………………… Do you drink alcohol? Yes No
Medical Information
Have you suffered from any of the following? If yes, please tick
Heart Disease/Angina Auto-immune disease HIV/Hepatitis
High/Low Blood Pressure Stomach Ulcer/Colitis Arthritis
Depression Thyroid Problems Skin disease (Acne)
Glaucoma/Cataract Facial Cold Sores
Diabetes
Bell’s/Facial Palsy Asthma/Bronchitis Convulsion
Other ……………………………………………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………………………………………….
Do you practice sport? Yes No if yes, please specify ………………………………………………………..
Do you have a blood clotting disorder/ require anti-coagulant treatment? Yes No
Are you pregnant, planning a pregnancy or breast feeding? Yes No
Are you currently taking medication? Yes No
Have you had any surgery in the past 3 months? Yes No
Do you have any allergies? Yes No
If you have answered YES to any of the above, please provide details
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Previous Treatment
Have you already had aesthetic treatment? Yes No
What was it with? HA Dermal Filler
Botulin Toxin Other
………………………………………………………………………………………………………………………………………………………………………………………………
Date of Treatment (month / year) Treatment Areas Name of products
INFORMATION SHEET
Before the treatment please read this document carefully
Don’t hesitate to ask questions if you feel the information is not clear
Your practioner, who is trained in the treatment techniques, will be available to answer your
questions Take the time you need before making your decision
1. PRODUCTS AND INDICATIONS
The product used includes cross-linked and non-cross-linked HA gels (cross-linking is a process which can transform a liquid
gel into a viscoelastic gel) as well as gels with or without anaesthetic (lidocaine).
The product used is designed for filling wrinkles and lines, contouring the face/body, skin rejuvenation or increasing lip
volume. This product has a 6 to 18-month duration, depending on several factors; skin type, the severity of the wrinkles to
be corrected, the injection zone and the volume injected. Your practioner will help you choose the product for injection
according to your desired results.
2. PRECAUTIONS FOR USE AND CONTRAINDICATIONS
Pregnant or breast-feeding women
Sports persons have to be alerted on the fact that this product contains an active compound which may lead a
positive reaction to doping testing
History of hypersensitivity to one of the components of the products tested (hyaluronic acid, lidocaine, vitamins)
or of anaphylactic shock or serve allergy
History of autoimmune disease or disease affecting the immune system (type 1 diabetes, polyarthritis,
rheumatoid arthritis, ankylosing spondylitis, psoriasis, thyroid disorder, scleroderma, inflammatory intestinal
disease, lupus, multiple sclerosis, ulcerative colitis)
Pathology (herpes, acne, rosacea) or unhealed skin alteration
Complications after surgery during the past 5 years
Previous injection of permanent products (silicone, acrylic, polymers, dextran)
Untreated infectious periodontitis, cellulitis or dental or ENT origin, dental abscess untreated or treated less than
one week ago
In association with a peeling, a laser or ultrasound treatment.
3. PRECAUTIONS FOR USE AND CONTRAINDICATIONS
The filler used has been available commercially for many years, with several million syringes injected. Based on current
data, there is no reason to suspect any unknown risks. According to international literature and health authorities,
hyaluronic acid-based products may potentially have side effects. Indeed, although hyaluronic acid is a natural constant of
the dermis, an injection of hyaluronic acid is likely to cause a skin reaction as if this molecule was a foreign body. These
reactions are usually temporary but influenced on the one hand, by many external factors (type of product, technique, site,
number of injections and quantity of product injected), on the other hand, by factors specific to the person being injected
(injection tolerance, nervousness at the time of injection, medical history).
Dissatisfaction with the expected aesthetic results
Redness, bruising, ecchymosis, haematoma, oedema, itching, mild pain at the injection point which may occur
after the injection and is resorbed after 24 hours to 8 days (on average 72 hours)
Indurations or nodules which may occur at the injection point 15 days to 3 months after the injection
Discolouration of the injection zone.
I have also been informed that rare cases of medical device vigilance have been described in the literature, necrosis in the
glabellar region, abscess, granuloma and hypersensitivity following injections of hyaluronic acid, however if you notice a
side effect after an injection, you must contact your practioner immediately.
CONSENT FORM
I agree to receive MyFiller dermal filler injections.
The area to be treated is ………………………………………………………………………………………………………………………………………………….
I hereby authorise....................................................................to treat me using MyFiller dermal filler. I understand that the
effects may not be 100% and that multiple treatments may be necessary to achieve the best results.
I understand that there are certain risks associated with MyFiller dermal filler. I certify that I have read the entire informed
consent and I agree to all its provisions. I certify that I have had the opportunity to ask questions and those questions have
been answered to my satisfaction. I fully understand the treatments conditions and procedure.
I agree to pay £.............for the above-mentioned services and understand there will be no refund for any performed
services. This consent form and cost covers above mentioned treatments only. Additional treatments can be added to this
consent form and will be charged for as per clinic price list.
I have been made award of the risk and I accept these terms and conditions as part of my treatment. My practioner will
not accept liability for any of the above side effects. By signing, I agree to the terms and conditions and in the event of any
of the above, I or any of my representatives, will not pursue the practioner in any means of compensation.
The objectives and methods of the injection/treatment procedure have been clearly explained to me by the
practioner
I have received, read and understood the information supplied by the practioner prior to the injection/treatment
I have had the opportunity to ask any necessary questions
I understand the pre and post injection recommendations and I agree to follow them
I acknowledge that I had the time required for consideration and to make my decision
I acknowledge that I have been clearly informed of the side effects and the rare cases of medical device vigilance
I freely and voluntarily consent to receiving injections/treatment
Client’s Name ……………………………………………………………………………..
Client’s Signature ……………………………………………………………………….
Date …………………………..
Practioner Name ………………………………………………………………………….
Practioner Signature ……………………………………………………………………
Date …………………………..
TREATMENT RECORD
PRODUCT STICKER
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