Hyaluronidase Informed Consent (DISOLVIDASE)

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Hyaluronidase Informed Consent (DISOLVIDASE)

DISOLVIDASE is an injectable that contains Hyaluronidase, a protein enzyme that breaks


down hyaluronic acid.
Hyaluronidase can be used to reverse the effects of hyaluronic acid fillers. DISOLVIDASE
is injected the same way as the dermal fillers were. The filler begins to break down
almost immediately after the injection of DISOLVIDASE, often making the results visible
to the patient right away. Additional injections may be necessary for further correction,
with at least one week between injections.
Disclosure:
Being fully informed about your condition and treatment will help you make the
decision whether or not to undergo DISOLVIDASE. This disclosure is not meant to alarm
you, it is simply an effort to inform you so that you may give or withhold your consent of
this treatment.
Possible side effects of Hyaluronidase include:
 Failure to dissolve and/or poor cosmetic result (depressions or unevenness)
 Tenderness, swelling, bruising, redness and pain around injection site
 Infection (very rare but can be delayed onset)
 Allergic reaction (very rare)
Consent:
1. I hereby authorize the following medical procedure: DISOLVIDASE.
2. I have been informed of the risks/side effects of the DISOLVIDASE injection.
3. I understand additional DISOLVIDASE injections may be required to reach
desired results.
4. I understand I have the right to refuse DISOLVIDASE.

By signing below, I acknowledge that I have read the above information and that I
understand the risks of Hyaluronidase injections. I hereby consent to DISOLVIDASE
injections, performed by the medical staff of Aries Dental and Aesthetic Clinic.

Patient name & signature:


Doctor name & signature:
Witness name & signature:

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