Aspley Injectables consent form

Clear full face photo required*

Name

First NameLast Name

Address

Phone

E-mail

DOB:

Medicare No.

DOB

Date

Position

Exp.

Medications

Allergies

Medical Conditions

Are you pregnant or breasfeeding?

Have you had any of the following conditions, tick all that apply

Have you had, or plan to have the COVID-19 vaccine within 2 weeks of this appointment?

YesNo

Do you have any cold/flu symptoms?

YesNo

Which area/s would you like treated:

Ensuring my privacy and confidentiality is maintained I consent to my before and after photos being used for demonstration and advertising purposes

I understand the nature of the procedure/s.

I confirm I have read and understand the before care instructions sent to me.

I confirm that all risks and benefits of the procedure/s have been explained to me and are fully understood by myself.

I acknowledge that I have been advised of the risks of this procedure/s.

I am aware that the procedure/s is not an exact science and that the results cannot be guaranteed.

No such guarantee has been given to me as to the results of this procedure/s.

I consent that I do not suffer from any of the contraidications listed for this procedure/s.

I certify that I am at least 18 years old or I have parental consent co-signed below.

I agree that this constitutes full disclosure, and that it supercedes any previous verbal or written disclosures.

I certify that that I have read, and fully understand the information given to me, and that I have had sufficient opportunity for discussion and to ask questions.

I consent to this procedure/s today and for all subsequent treatments.

Signature*

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Prescription Form

Medication –
Botulinum Toxin Type A 100 units/vial (OnabotulinumtoxinA)
Botulinum Toxin Type A 500 ISPEN units/vial (AbobotulinumtoxinA)
Hylaluronic Acid 20mg/ml, 18mg/ml, 24mg/ml or per product make.
Xylocaine 2% 100mg/5ml for injection
Deoxychloric Acid 20mg/2ml (10mg/ml)
Hyaluronidase 1500iu per vial
Sculptra Poly-L-lactic acid 150mg per vial

Directions for use – Facial tissue augmentation, muscle relaxation, fat dissolving, the treatment of fine lines & wrinkles, dissolving hyaluronic acid treatments.
To be administered by: Registered Nurse
To be administered at: Injex Clinics – 1A, 8-16 Redland Bay Rd, Cnr Dollery Rd, Capalaba, QLD, 4157
Injex Clinics - 1401 Gympie Rd, Aspley, Qld, 4034

Botulinum toxin type A treatment:
Frown/glabella – up to 60units dysport or up to 30units botox.
Forehead/frontalis – up to 60units dysport or up to 40units botox
Crows feet – up to 120units dysport or up to 60 units botox. Masseter muscles – up to 200 units dysport
Platysmal bands – up to 80 units dysport. Nasal lines /compressor naris – up to 20 units dysport
Nasal flare/dialator naris – up to 20 units dysport. Gummy smile/levator labii superioris alaeque nasi – up to 12 units
Depressor Anguli Oris/Marionette lines – up to 20 units dysport. Upper lip lines/ vermillion border – up to 24 units dysport
Mentalis/chin – up to 20 units dysport. Axillar for hyperhidrosis – up to 200u/side dysport

Hyaluronic acid treatment:
Juvederm & Restylane range up to 8ml per treatment - needle and cannula using bolus and linear thread technique for deep dermal, to subdermal enhancement.
Areas for injection: Lips,Cheeks, Nasolabial folds,Marionette lines, Oral
commissures,Chin,Jaw line,Jaw enhancement,Nasojugal groove,Tear trophs,Full face facial hydration with Restylane Vital, Temples,Fine lines on face, neck and décolletage,Hands and Fingers

Deoxychloric Acid treatment:
Deoxychloric Acid Solution up to 8ml per treatment – for treatment of submental adipose tissue using cannula and needle techniques.

Hyaluronidase treatment:
Hyaluronidase for the treatment of dissolving excess hyaluronic acid PRN.

Sculptra Poly-L-lactic Acid treatment:
Sculptra Poly-L-lactic Acid up to 5 vials per treatment - for treatment of subcutaneous or deep dermis injection.

I, have viewed the patient and their medical history and deem them to be
eligible for treatment by the Registered Nurse.

Dr. Alex Ha
Injex Clinics
Prescriber number: 2244552
Signed:

_________________

Dr. David Seton
Injex Clinics
Prescriber number:
2109442
Signed:

_________________

Dr. Arun Nayak
Injex Clinics
Prescriber number:
2328560

Signed:

_________________

Dr Signature

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Prescribing Doctor*

Doctors notes