At Apple Tree Aesthetics, we work with you to identify the most suitable treatments after a face to face consultation where your needs and concerns are recognised and a treatment plan is made.
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Dermal Fillers – Apple Tree Aesthetics
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Dermal Fillers

Apple Tree Aesthetics / Dermal Fillers
Aesthetics consultation form – Dermal Fillers
Please fill out your details below for our team to contact your to arrange the next steps.

Full Name:
Date of birth:
Address:
Postcode:
Mobile number:
Email address:
GP surgery:
Emergency number:

Do you have any medical conditions
YesNo

Are you taking any medicines?
YesNo

Do you have any Drug allergies?
YesNo

Are you pregnant/breast feeding/undergoing IVF?
YesNo

Have you had dental work in the past?
YesNo

What is your occupation?

Do you exercise regularly?
YesNo

Have you had any surgery?
YesNo

Have you had any aesthetic surgery?
YesNo

And when:
≤ 1 month≤ 3 months≤ 6 months≤ 1 year≥ 1 year

Have you already undergone aesthetic procedure?
YesNo
If yes please specify:
botulinum toxindermal fillerskin peeldermabrationlaseror any other
And when:
≤ 1 month≤ 3 months≤ 6 months≤ 1 year≥ 1 year

Please specify where:

If you have had previous treatment with dermal fillers, do you know which brand of dermal filler was used?
YesNo

Did these previous procedures cause any undesirable reactions?
YesNo

Consent

Dermal fillers:
At Apple Tree Aesthetics we use a range of cross-linked (a process which can transform a liquid gel to a viscoelastic gel) and non-cross-linked hyaluronic acid with or without lidocaine (anaesthetic). All products are sterile and non-animal origin for injection for filling wrinkles and lines, correction and or increasing volume. Cross-linked products have a range of 6-18 months duration. This mean duration can have several factors: the patient’s skin type, the severity of the wrinkle to be corrected, the injection zone, and volume injected. Non cross-linked hyaluronic acid gels are designed to improve skin hydration and radiance. The practitioner will help choose the product for injection according to your aesthetic requirement.

Precautions and contraindications
- Pregnant and breast-feeding women or those undergoing IVF treatment.
- History of hypersensitivity to one of the components of the products (hyaluronic acid or lidocaine) resulting with anaphylactic shock or severe allergy.
- History of autoimmune disease affecting the immune system (precaution) (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 a surgery during the past 5 years;
- Previous injection of permanent products (silicone, acrylic polymers, dextran);
- Untreated infectious periodontitis, cellulitis of dental or ENT origin, dental abscess untreated or treated less than on week ago.
- In assosciation with a peel, laser treatment or based on ultrasound.

Side effects
- Indeed hyaluronic acid is a natural constituent of the skin and injection of hyaluronic acid is likely to casue a skin reaction as if a molecule of a foreign body. These reactions are usually temporary but influenced by many external factors the product, number of injections and quantity of product) and some specific factors to the patient injected (patient tolerance, nervousness and medical history).
- Redness, bruising, hematoma, oedema, itching, mild pain at the injection site which may occur after the injection and up to 8 days (on average 72 hours).
- Swelling or firmness a the treatment site.
- Nodules which may occur at the injection point 15 days to 3 months after the injection
- Discolouration of the skin in the injection zone.
- Rare risks include: allergy including anaphylaxis
- Very rare risks include: skin necrosis, visual disturbances or blindness.

Consent for Injectable Treatment:
- I have discussed my medical history fully with my practitioner, including side effects of complications of my treatment relating to these conditions.
- The use of, and indications, for the products I will be treated with have been explained to me by my practitioner.
- I have discussed realistic expectations with my practitioner.
- I understand that results cannot be guaranteed and my practitioner will use their best judgement.
- I have had the opportunity to have my questions answered.
- I have discussed aftercare instructions with my practitioner to gain optimal results from my treatment.
- I am aware that the duration of effect of treatment can be shorter or longer than stated in an individual patient.
- I have been specifically informed of the following common injection related reactions: redness, swelling, pain, itching, bruising and tenderness at the treatment site. These reactions are mild to moderate and typically resolve within a few days.
- Repeat treatment will help to maintain the desired correction in the long term.

Patient Statement
I am aware that the treatment performed and my personal details, any images taken and clinical notes will be used as part of the practitioners’ confidential portfolio.
My practitioner has advised me of the amount if product required and the cost of the treatment, which I have already paid, or will pay immediately after treatment for any additional treatment received.
I certify that I have read the above information fully and understand the complications that could occur.
I have had sufficient time for discussion with my practitioner and agree to treatment today.
The information that I have provided is to the best to my knowledge correct.
I confirm the medical questionnaire is up to date and correct at the time of treatment.
I have expressed my thoughts and feelings to the practitioner and consent to treatment for the purpose of restoring and maintaining my health and my psychological wellbeing.

I herby consent to treatment.
YesNo

I have read and agree to Apple Tree Aesthetics terms and conditions.
YesNo