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MP 0636355 • SAMA 74851 • MPS 01/39363 • PR 0511242 WHAT ARE DERMAL FILLERS?Dermal fillers are injectable treatments to reduce the appearance of lines and wrinkles. The most widely used products contain hyaluronic acid such as Restylane, Perlane and Juvederm.Ask your doctor which filler is being used since the regulations at present are not very demanding and a product can be promoted after minimal WHICH AREAS CAN BE TREATED/IMPORVED? • deep 'smile lines' which run from the side of the nose to the corners of the mouth • 'crows feet' at the corner of the eyes • smokers lines' which are vertical lines on the top lip • marionette lines' at the corner of the mouth • 'worry lines' which run across the forehead HOW LONG WILL THE RESULT LAST?Treatment with dermal fillers is not going to be successful for every person, and results and duration are variable.
However, depending on the filler used duration can vary from 6 to 18 months.
michelle@docmaartens.co.za • 0 747 669 911 Leisure Bay Unit 211 • 3 Fourjay Road • Milnerton • Cape Town • 7441 MP 0636355 • SAMA 74851 • MPS 01/39363 • PR 0511242 PRECAREOne week prior to your injection, we advise you to avoid using alcohol, garlic, lidocaine and aspirin, or any other non-steroidal anti- inflammatory drugs for pain, swelling and/ or fever, such as medicines containing diclofenac, mefenamic acid, indometacin or ibuprofen- ask your doctor or pharmacist whether your medication includes any of these ingredients. Following these instructions will reduce the risk of bruising or bleeding at the point If this is your first, you will need to provide your medical doctor with information on your medical history and any allergies you have or medications you are taking. There is no need for an allergy test, unless your medical Because inject able gel is a relatively simple, non- surgical treatment, there is minimal recovery time. For the first 24 hours following treatment, you should avoid strenuous exercise, excessive sun or heat exposure, and alcoholic beverages in order to help minimize the risk of temporary redness, swelling and/ or itching.
No treatment can halt the ageing process; you will require top-ups if you want to maintain the effect so ask your medical doctor when they would recommend rescheduling another appointment.
michelle@docmaartens.co.za • 0 747 669 911 Leisure Bay Unit 211 • 3 Fourjay Road • Milnerton • Cape Town • 7441 MP 0636355 • SAMA 74851 • MPS 01/39363 • PR 0511242 Patient Name_______________________Date of Birth______________ Street Address_______________________Town_______Postcode_____ Contact number__________Mobile___________Email______________ G.P. Name and address_______________________________________ Are you attending or receiving treatment from a doctor or specialist (Y/N) Are you taking any medication, or herbal remedies (including antibiotics, anticoagulants, Muscle Relaxants, St Are you taking blood thinning medication (Aspirin, Plavix, Warfarin) ? (Y/N) Are you allergic to local anaesthetic injections, lignocaine, adrenaline or EMLA/ANESTOP cream? (Y/N) Do you have any known allergies or a history of anaphylaxis? (Y/N) Have you suffered from or had any of the following conditions.
Heart Problems including an irregular heartbeat or angina (Y/N) High or Low Blood Pressure or circulation problems including Raynaud’s Syndrome (Y/N) Blood disorders/leukaemia/lymphoma/anaemia (Y/N) Keloids (hypertrophic scarring) or recent scar tissue (6 months) (Y/N) Are you pregnant/planning pregnancy/engaged in IVF treatment or are you breast feeding? (Y/N) Have you had a consultation or been treated with a dermal filler before? (Y/N) Have you had an allergic reaction to any dermal filler product? (Y/N) Have you had a consultation or had plastic surgery or are you planning to have surgery? (Y/N) What are your expectations of treatment? (please discuss with Doctor) The time period before the treatment is effective is 2-14 days. The treatment will last between 3-9 months.
Potential complications and side effects include: • Ptosis; especially if treating forehead • Unwanted arching of the eyebrows; if treating crows feet, forehead but especially frown lines • Bruising and swelling at site of injection- or a black eye • Treatment may not work; everyone is different. Rarely, wrinkles can become worse • Migraine, Temporary double vision, possible temporary numbness Whilst results are not guaranteed, the Doctor will provide treatment to the best of his knowledge and experience of advanced dermal filler treatments.
I hereby give my consent to the doctor to be treated with dermal fillers for cosmetic use. I have been informed about the risks and possible side effects of treatment and accept these risks as my own. I have understood and correctly completed the medical history form.
Patient Signature____________________ Doctor Signature ___________________ Date _______________ Like any medicines, LMX4 cream, lignocaine and adrenaline may sometimes cause side effects. These are usually mild, but in rare cases, local anaesthetics have been associated with allergic reactions including rashes, swelling, very low blood pressure or an irregular heartbeat.
I hereby give my consent to the doctor to be treated with local anaesthetic. I have been informed about the risks and possible side effects. I have understood and correctly completed the medical history form.
Patient Signature____________________ Doctor Signature ___________________ Date _______________ michelle@docmaartens.co.za • 0 747 669 911 Leisure Bay Unit 211 • 3 Fourjay Road • Milnerton • Cape Town • 7441

Source: http://www.docmaartens.co.za/dermal-fillers.pdf

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