Informed Consent for Hyaluronidase (Hyaluronic Acid Dissolver) Injections

This consent form confirms that I have been fully informed and educated regarding hyaluronidase injections, including their purpose, mechanism of action, expected benefits, alternatives, limitations, risks, and possible complications. I acknowledge that I have received adequate information to make a voluntary and informed decision regarding treatment.

Prior Injectable Disclosure

I acknowledge that I have informed my provider of any previous dermal filler or biostimulator injections, including product type, treatment dates, and anatomical areas treated.

Nature & Purpose of Hyaluronidase

• I understand that hyaluronidase is an enzyme used to break down hyaluronic acid–based dermal fillers.
• I understand that hyaluronidase may be used to reduce or reverse unwanted filler results, correct asymmetry or overcorrection, treat filler-related complications, or assist in the management of suspected vascular compromise, which may constitute a medical urgency.

Procedure Description

• I understand that the procedure involves the use of a needle and/or cannula to inject hyaluronidase into affected tissue.
• I understand that results may be seen after the first treatment; however, multiple treatment sessions may be required to achieve the desired outcome.

Gradual & Conservative Treatment Approach

• I understand that hyaluronidase may also break down the body’s natural hyaluronic acid, which may temporarily affect skin volume, hydration, or appearance.
• I understand that for this reason, treatment is often performed conservatively and incrementally, and additional sessions may be scheduled rather than dissolving all filler at once.

Alternative to Treatment

• I understand that an alternative option is to allow dermal filler to naturally metabolize over time, which may take several months or longer depending on filler type, amount injected, and anatomical location.

Expected Results & No Guarantee

• I understand that although improvement is expected, medicine is not an exact science and no specific result can be guaranteed, either expressed or implied.
• I understand that I am paying for professional medical services, not for a guaranteed aesthetic outcome.

Alternatives to Hyaluronidase

• I understand that alternatives may include observation, time, additional filler adjustment, camouflage with other treatments, or no treatment at all.
• I confirm that these alternatives have been discussed with my provider and that I have had the opportunity to ask questions.

Medical Disclosure & Contraindications

• I agree to fully disclose all medical conditions, allergies, and medications, including supplements.
• To the best of my knowledge, I have no known allergies or sensitivities to hyaluronidase.
• I understand that hyaluronidase carries a risk of allergic reaction, including anaphylaxis.
• I understand that a patch test may be performed prior to treatment, commonly on the forearm, to observe for signs of an allergic reaction such as hives or wheals.
• I understand that injectable treatments may trigger cold sore or herpes simplex outbreaks and have informed my provider if applicable.
• I deny that I am currently pregnant, attempting to become pregnant, or breastfeeding. I understand that the safety of hyaluronidase during pregnancy and breastfeeding has not been established. If uncertain, I will request pregnancy testing prior to treatment.

Risks & Possible Complications

I understand that all injectable procedures carry risk. Potential risks associated with hyaluronidase injections include, but are not limited to:

• Discomfort or tenderness
• Bleeding or bruising
• Swelling, often temporary
• Infection (rare)
• Scarring (rare)
• Allergic reactions, including anaphylaxis
• Unintended overcorrection or undercorrection
• Breakdown of native hyaluronic acid
• Unknown or unforeseen side effects

Patient Variability & Delayed Reactions

I understand that individual responses vary and that delayed reactions may occur. I agree to contact AI Wellness Center of Excellence immediately if I experience any unusual, worsening, or concerning symptoms.

Emergency Use Acknowledgment

I understand that in certain situations, hyaluronidase may be administered urgently to address suspected vascular compromise or other serious filler-related complications, and I consent to its use if deemed medically necessary by my provider.

Post-Treatment Responsibility

I understand that it is my responsibility to notify the clinic promptly of any adverse effects or concerns and to allow AI Wellness Center of Excellence the opportunity to evaluate and participate in my care.

Authorization & Provider Qualifications

• I hereby authorize Dr. Gideon Kwok, D.O., and/or trained and qualified licensed medical providers acting within their scope of practice to perform hyaluronidase injections.
• I acknowledge that I have had the opportunity to inquire about the qualifications and experience of the provider administering my treatment and that I am satisfied.
• I affirm that my consent is voluntary, informed, and freely given.

Final Acknowledgment

I acknowledge that I have read and fully understand this consent form, that all disclosures have been explained to me, that I have had the opportunity to ask questions, and that this form supersedes any prior verbal or written disclosures. I freely consent to hyaluronidase injections.