Hyaluronidase Injection Consent Form
Please review and complete this form to provide your informed consent for the hyaluronidase injection procedure.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Have you ever had an allergic reaction to hyaluronidase or other injectable agents?
*
No
Yes, to hyaluronidase
Yes, to another injectable agent
Are you currently taking any medications or supplements?
*
No
Yes, prescription medication
Yes, over-the-counter medication
Yes, supplements/herbals
Please list any current medications, supplements, or allergies.
Do you understand the risks, benefits, and possible side effects of the hyaluronidase injection procedure?
*
Yes, I understand and have had the opportunity to ask questions.
No, I would like more information.
Emergency Contact Name and Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Consent
Should be Empty: