Thread Consent Form

Medical history

Thread Lift Consent Form
Name *

First Name Last Name
Date of Birth *

Day Month Year
Address *

Street Address

Street Address Line 2

Postcode
Mobile phone *
Email *
example@example.com
Please select any conditions that apply to you:

Rheumatic fever Pacemaker Epilepsy Diabetes Heart problems Liver or Kidney disease Asthma Heart murmur Jaundice Chest problems High blood pressure Hepatitis Hayfever Bleeding disorder Heart surgery Blackouts/ Fainting attacks/ Giddiness Any tablets for cancer or osteoporosis Bad reaction to general anaesthetic Bad reaction to local anaesthetic Hospitalised for any operations/serious conditions in last 5 years Taken steroids in last 2 years Do you carry a warning card Are you seeing a doctor at present Had a joint replaced Have used needle delivered recreational drugs I have ALLERGIES I take pills/medications
I have these allergies:
I take these pills/medications:
If female, are you or do you think you may be pregant?
If you smoke, how many cigarettes do you smoke per day?
If you smoke, how many years have you smoked for?
How many units of alcohol do you drink per week?
How many times per day do you brush your teeth?
Do you brush your teeth with fluoride toothpaste? *
How often per week do you floss your teeth?
Name and address of your doctor: *
Please select any conditions that apply to you (contraindications for polydioxanone - pdo - thread lift treatment):

Pregnancy or breast-feeding Active infection in the treatment area (eg herpes simplex, pustular acne, cellulitis). Hypertrophic or Keloidal scarring Bleeding abnormality (eg thrombocytopenia, anticoagulant use) Impaired healing (eg immunosuppression) Skin atrophy (eg chronic oral steroid use, ehlers danlos syndrome) Active dermatoses in the treatment area (eg psoriasis, eczema) Roaccutane use within the last 6 months Uncontrolled systemic condition Previous anaphylactic reaction Multiple severe allergies Sensitivity or allergy to constituents of filler (polydioxanone) Unrealistic expectations or body dysmorphic disorders Severe needle phobia
Information - Polydioxanone threads

PDO threads, once inserted, are completely absorbed with only new collagen remaining after 6 months. Threads are non-allergenic and discomfort after insertion is mild to moderate lasting usually 3-4 days re- quiring pain killers like paracetamol 2-3 times a day after meals. Anti- inflammatory drugs (e.g. Ibuprofen) are not recommended because this category of drugs reduces inflammation and can reduce collagen formation.

Generally bruising associated with the polydioxanone thread insertion is minimal, but clients on aspirin or other blood thinning medicines are prone to slightly more bruising. Aspirin prescribed for a medical indica- tion should not be terminated, however, bruising is more likely.

Some degree of swelling can be expected lasting about 2-3 days. We may also recommend an oral anti- histamine to reduce any swelling prior to treatment. Patients at risk of Cold sores are advised to take pro- phylactic aciclovir tablets and should apply topical cream, especially if threads are to be inserted around the lips.

We advise you to stop taking all blood ‘thinning” supplements such as Evening Primrose Oil, Vitamin C and Vitamin E and certain herbs.

All existing facial asymmetry may not be completely rectified.

Follow up review consultations are recommended after 1 month and 3 months. However, in the event of any concerns whatsoever, please contact the clinic immediately on 0141 552 8898.

Polydioxanone (PDO) Thread Treatment Consent

Polydioxanone threads are used for the treatment of facial creases, wrinkles, folds, contour defects, depression scars, facial lipoatrophy (loss of fat) and enhancement purposes. These treatments involve multiple injections of filler threads into or below the skin to fill wrinkles and restore volume. The effects of PDO threads are temporary and no guarantees can be made regarding how long correction will last in a specific patient. Alternatives to Polydioxanone threads include, but are not limited to: temporary dermal fillers, laser resurfacing and skin tightening, surgical facelift or no treatment at all.

Possible risks, side-effects, and complications with polydioxanone threads include but are not limited to:

• Bruising, redness and swelling
• Visible raised areas or bumpiness at/around the treated site
• Asymmetry, over correction or under correction.
• Unpredictable persistence of filler, either shorter or longer than anticipated
• Prolonged discolouration of the skin such as brown, greyish, bluish or reddish colouration.
• Filler material may be extruded from the skin in rare cases
• Prolonged or severe swelling
• Infection
• Rarely granulomas or firm nodules may form
• Benign tumour formation (keratoacanthomas)
• Allergic reaction with itchiness, redness and in extremely rare cases generalised allergic response such as a whole body
swelling, respiratory problems and shock
• Scarring is extremely rare
• Skin breakdown or ulceration
• Facial nerve trauma is a possible but rare complication
• Blindness
Post-treatment Procedure:
• Applying something cool to the treatment area will reduce swelling
• Applying SPF30+ and avoiding direct sunlight & tanning machines will prevent post Inflammatory Hyperpigmenta- tion (PIH)
• Do not wash your face on the same day after the procedure. Gentle cleansing is allowed from the next day, do not rub or
massage the area for 2 weeks.
• Do not open the mouth wide and do not have routine dental treatment for at least 4 weeks after the treatment.
• Avoid alcohol and taking aspirin for 7 days after the treatment (unless for medical reasons).
• Avoid extreme temperatures (sauna, sunbed etc.) and exercise for 7 days after the treatment.
• Avoid having other cosmetic treatment for 14 days after the treatment.
• A stinging or “pulling” pain or discomfort is normal.
• Antibiotics will be supplied and, if indicated, the course should be completed.
• Avoid having Radio Frequency (RF) or any heat producing device (laser, IPL, etc.) treatments of the thread treated areas for at
least 10 weeks.

Take paracetamol 500 mg 1-2 tablets 6-hourly as required. Avoid taking any anti-inflammatory medication (until 7 days after treatment) such as Nurofen, because inflammation is necessary to initiate the new collagen formation process.

For most complications there are no corrective treatments and they spontaneously resolve as the polydioxanone thread dissolves.
My signature below certifies that I have fully read this consent form and understand the written information provided to me regarding the proposed procedure. I have been adequately informed about the procedure including: the po- tential benefits, risks, limitations and alternative treatments and I have had all questions answered to my satisfac- tion. Please note audiovisual recordings may be taken for records.
Signature *

Clear
Patient Instructions:

Thread lift

Before treatment:

• A full consultation with our medical practitioner to ensure you are an ideal candidate for treatment.
• We MAY supply you with an oral anti-biotic to take one hour before the procedure and for 2 additional days to reduce the chance of infection.
• We may also recommend an oral antihistamine to reduce any swelling prior to treatment. • Aspirin prescribed for a medical indication should not be terminated. However, bruising is
more likely.
• Patients at risk of Cold sores are advised to take prophylactic acyclovir tablets and should
apply topical cream, especially if threads are to be inserted around the lips.
• Arnica tablets taken from about 5 days pre-treatment may be beneficial in reducing swell-
ing after the treatment.
• We advise you to stop taking all blood ‘thinning” supplements such as Evening Primrose
Oil, Vitamin C and Vitamin E and certain herbs.

General injection related complications:
- Pain
- Bruising
- Redness
- Swelling
- Tenderness
- Headache
- Infection
- Numbness
- Anxiety
Most will resolve in a few hours or a few days.
Patient Covid-19 Screening
Have you tested positive for COVID-19 in the last 7 days? *

yes no
Are you waiting for a COVID-19 test or the results? *

yes no
Do you live with someone who has either tested positive for COVID-19 or had symptoms of COVID-19 in the last 14 days? *

yes no
Do you have any of the following symptoms:

New, continuous cough*; High temperature or fever; Loss of, or change in, sense of smell or taste?
* A new, continuous cough means coughing for longer than an hour, or
three or more coughing episodes in 24 hours. If the patient usually has a
cough, it may be worse than usual.

If you have answered YES to any of the above, you should not attend the practice.

If you have recovered from COVID-19, or completed a period of self-isolation, you are able to attend the practice.

A person is considered to have recovered from COVID-19 infection when
they meet all of the following criteria:
• It has been at least 7 days since the onset of the COVID-19 symptoms;
• They no longer have a high temperature.
N.B. A cough may persist for several weeks in some people, even though the coronavirus infection has cleared. The loss of, or change in, sense of smell or taste may also linger. According to the CMO letter (18 May 2020) a person with a persistent cough and/or loss of sense of smell or taste but no other symptoms does not need to continue to self-isolate for more than 7 days.
I hereby declare that the information provided is complete and accurate. I fully understand that any false information can put the healthcare workers attending to me at a higher risk of contracting COVID-19 disease. I fully agree to follow all the instructions regarding precautionary steps by the treating clinician and staff at the clinic.
I am visiting the clinic with full knowledge that we are going through a COVID-19 global pandemic.
There is always a risk of contracting this virus when I am visiting a place during this pandemic.
There is a possible risk of getting this virus by visiting any place during this pandemic. I have been fully explained the content of this declaration form in a language that I can understand.
I hereby absolve the treating clinician and the team members of Royston Dental Practice / freshfaced of any criminal or medicolegal liability arising due to my visit to the clinic. I hereby give my consent for this.
Signature *

Clear
Should be Empty:

Medical history