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Hyaluronidase Informed Consent

Indication

Hyaluronidase is a protein enzyme used in the cosmetic field to dissolve dermal fillers. This is considered “off label” by the FDA. There are other FDA approved uses for this agent such as adjuvant in fluid administration for achieving hydration and to increase the dispersion and absorption of other injected drugs. These uses are considered “on label”. Hylauronidase, a protein enzyme, is used to beneficially break down hyaluronic acid specific locations.

Because of its enzymatic reaction with hyaluronic acid, it can be used to correct the effects of cosmetic hyaluronic-acid filler injections such as Restylane®, Juvederm®, Belotero®, Versa™ and Voluma®, which are used to treat facial wrinkles.

Application

In terms of its cosmetic application, hyaluronidase may be indicated if previous hyaluronic acid injections used to smooth out bags or wrinkles have produced an unfavorable result the patient is unhappy with. It can be injected to remove just uneven bumps or lumps, or it can be injected to reverse the effects of the entire procedure. Anyone who is unhappy with the look of his or her cosmetic filler procedure would be considered a candidate for correction with hyaluronic acid. If the first treatment does not produce the desired results, the injection can be repeated to achieve more complete resolution. Most doctors recommend a week or so between subsequent injections.

If the dermal filler injection that is being reversed was administered by Pure Cosmetics, there is no cost associated with the reversal. However, if another facility or practice has administered the dermal filler injection, we strongly reccommend that you notify the practice that provided treatment and have them rectify the dissatisfaction. If you choose to have Pure Cosmetics reverse a dermal filler injection from another practice, there is a fee associated with the reversal.

Recovery

Recovery time is minimal. The procedure and recovery are virtually the same as they were for the original cosmetic filler injection. There is virtually no down time with either procedure. There may be some temporary, minor tenderness, swelling or redness at the injection site but any residual discomfort should be minor, if any is noticed at all. You should know relatively quickly what results you will achieve after an injection of hyaluronidase. The hydrolysis or breaking down of the filler tissue starts immediately and is readily visible. Your doctor may recommend repeated injections for further correction.

I have read over the indications, application and recovery information about Hyaluronidase. I acknowledge that all of my questions have been answered about the indications, application and recovery.

Important Safety Information

Hypersensitivity to hyaluronidase or any other ingredient in the formulation is a contraindication to the use of this product. The most frequently reported adverse reactions have been local injection site reactions, such as erythema, bruising and pain. Dissolution of all of the dermal filler can occur. 

Consent

I agree that Pure Cosmetics and the company's designated staff and associates may take photographs and/or videos of me during and/or immediately after my procedure, as well as subsequent office visits. I understand that these photographs must be taken for my medical records and agree to use them for education and promotion.

I agree to not hold Pure Cosmetics liable and responsible for any dermal filler injection results from another practice or service provider and do have the option to go to the practice that provided the treatment. Additionally, I agree to not hold Pure Cosmetics responsible for any treatment prior to today's injection from another facility, practice or service provider unaffiliated with Pure Cosmetics.

I hereby acknowledge that I have requested a hyaluronidase treatment from Pure Cosmetics, PLLC. I understand that no guarantee can be made as to the result of treatment. 

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Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
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By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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