WILLIAM BLANE RICHARDSON, MD

| SOUTHERN GRACE PRECISION & AESTHETICS

WILLIAM BLANE RICHARDSON,MD

SOUTHERN GRACE PRECISION & AESTHETICS

Hyaluronidase (Hyalase®) - Informed Consent

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YOUR CONSULTATION TODAY

This form is not just a formality - it’s a record of your decision to consent to a procedure having considered the risk of both positive and negative outcomes and medical risks listed below, and the impact they may have on your well-being.

Risks of the procedure include but may not be limited to:
  • Risks of injection:
  • Trauma during the procedure is caused by needles and cannulas passing through tissue, and includes bleeding, bruising, hematoma (a larger collection of blood in the skin, outside of blood vessels), damage to underlying structures including veins, arteries, nerves, salivary glands, lymph nodes, bone, muscle and other soft tissue structures are possible. In rare cases this could cause continuous problems in appearance, sensation or function and may require medical intervention to treat or may be permanent. Most traumatic injuries heal completely on their own.
  • Reactions:
  • Allergic reaction including anaphylactic shock are possible, they occur at a rate of between 1/2000 and 1/100 depending on the data source. Anaphylactic shock has a mortality rate 0.3 to 5% depending on the study. An allergy test can often identify this risk prior to full exposure. Local reactions include oedema, erythema, pain and itching, urticaria and angioedema.
  • Side Effects:
  • Hyaluronidase dissolves hyaluronic acid including molecules made by your body and previous treatments that you may wish to preserve could also be dissolved. You therefore could notice a reduction in skin elasticity and volume and associated asymmetry which typically would last a few days. It is common to cause bleeding, bruising, some swelling or oedema and redness near the injection site.
  • Treatment Failure:
  • It is possible that the procedure will fail to remedy the problem as often HA is not the sole cause of lumps, bumps or reactions. which may be caused by other materials.
  • Complications from infection:
  • There is a small risk of introducing an infection, and a theoretical risk that pre-existing infection could spread further if hyaluronidase is injected into the area, risking septicemia though their are no recorded cases.
  • I confirm I do not have any know allergies to hyaluronidase, and to my knowledge I do nothave any active cancers in the area injected, nor am I pregnant or breastfeeding.
  • Follow-up:
  • I understand adjustments requiring more product incur a charge.
  • Dissatisfaction:
  • I understand that with all treatments the precise degree of improvement cannot be guaranteed. The outcome’s subjective nature also means dissatisfaction is a possible outcome regardless of effectiveness of treatment. I understand that the effect of all treatments may gradually wear off, additional treatments may be necessary to acquire the desired effect, and further charges will apply if more product is required.
  • Agreement:
  • By signing this form, I agree that I have read this form carefully and considered the side effects, risks and uncertainty of the outcome and decided the treatment is still in my best interest. I have discussed all the details of the treatment plan, past treatments and my medical history with my clinician and shared all the information my clinician may need to plan a treatment. I agree that the balance of the benefits and risks to my overall favor the use of Hyalase. I understand that the initial treatment of side effects and complications is included in the cost of the procedure and therefore no refunds are issued due to any of the above occurring. I understand photographs are taken and stored for 7 years as part of my clinical record.

    ACKNOWLEDGMENT
    BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR THE PROCEDURE, AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION BY MY HEALTHCARE TEAM.
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