Corticosteroid Injection Consent Form
Product/Treatment Information:
Triamcinolone is a synthetic glucocorticoid corticosteroid medication injection that has marked anti-inflammatory action. It is prepared in a sterile aqueous suspension suitable for injecting directly into a lesion on or immediately below the skin to treat a dermal inflammatory process. It is indicated for many skin conditions, including for the treatment of keloids and hypertrophic scars. Evidence has shown that, when injected, Triamcinolone steroid significantly reduces keloid and hypertrophic scar tissue.
We advise the use of silicone gel spray or sheets for 12 to 24 hours per day for two to three months following injection. One of the better-known brands for this is Kelocote. This may increase the success of scar tissue reduction and prevent its return. You may wish to do this as a standalone treatmentment before steroid injection as it can be effective, however, evidence shows that it is not as efffective as dual therapy with silcone cover and a steroid injection.
No two scars or treatments are the same. Depending upon your scar tissue, you may require multiple treatments, which will be discussed and assessed over time. We would expect to see you every four weeks for steroid injection treatment until the scar has resolved, or we do not anticipate any further recovery.
Alternative Treatments
Other treatments for scar tissue management are available and may be discussed with your practitioner at any time. If you feel that the risks and side effects associated with steroid injections are not acceptable to you, you should consider discussing an alternative treatment with your practitioner or no treatment at all.
Contraindications:
You cannot have a steroid injection if:
You have or have a history of malignant (cancerous) skin lesions.
You have had roaccutane/Isotretinoin oral medication in the last six months..
You have an active infection or inflammation near the intended treatment area, including active acne lesions.
You have open wounds in the intended treatment area.
You have an active outbreak of herpes simplex infection (Cold sores) in the treatment area.
Have had, or expect to have, a live virus vaccine within two weeks of steroid injection.
You have uncontrolled diabetes or poor wound healing.
You are immunosuppressed.
You had a heart attack under one year ago.
You have uncontrolled congestive heart failure.
You have uncontrolled epilepsy.
You have uncontrolled hormonal disorders.
You have uncontrolled hypertension (high blood pressure).
You have had or are susceptible to blood clots or uncontrolled bleeding.
You have had facial fillers or botox in the intended treatment area under two weeks before treatment.
You think you could be pregnant, are pregnant, or are lactating/ breastfeeding.
Cautions:
You need to tell your aesthetic practitioner if:
You suffer from recurrent herpes simplex infections (cold sores). A steroid injection may encourage an outbreak.
You use topical retinol or retinoid prescription medications in the treatment area. Repeated steroid injections may thin your skin and make you more sensitive to retinoid products.
Material Risk (the level of significance you personally apply to the risks, side effects or complications of this treatment within your own circumstances):
As with any medical procedure, this treatment carries the risk of side effects or complications. Discuss these risks with your practitioner to fully comprehend their implications. Consider the risks in relation to your personal circumstances, including your health, lifestyle and career and decide if they are acceptable. If not, discuss alternatives or take more time to decide.
Associated Risks:
Pain
Impaired wound healing
Increased hair growth
Bleeding
Skin necrosis/ulceration (skin cell death leaving an open wound)
Hypopigmentation/Hyperpigmentation (white or brown marks on the skin)
Steroid acne
Infection
Telangiectasia (superficial blood vessel growth)
Skin thinning
Cutaneous and subcutaneous lipoatrophy (most common) appear as skin indentations or dimples around the injection sites a few weeks after treatment.
Systemic side effects (outside of the injected area) include Cushing syndrome, weight gain, moon face, muscle loss, thinning hair, bruising easily, and thinning skin. These are usually seen after continuous use of high-dose steroids but can rarely occur after just a single keloid injection.
Dissatisfaction. Not all skin conditions and types are the same and may not respond as expected. Your skin’s response may be subject to variation. Although the overwhelming majority of patients who receive a steroid injection report a near-complete clearance of keloid or hypertrophic scarring, there is always a possibility that you may not see an appreciable reduction or that it may return once treatment has finished. We will always try our best to help you achieve your expectations; however, you must be aware that, even in these circumstances, we will not refund the treatment.
Photographs:
We need to take photos of the treatment area to document the original condition before treatment begins and to monitor results and potential changes throughout the treatment process. These photos will become part of your medical aesthetic treatment record at Lumiere Medispa.
You have the right to refuse consent for these photographs. However, please be aware that without this consent, we will not be able to treat you for medico-legal reasons.
If we wish to use your photos for any other purpose, we will always seek separate written consent from you. You have the right to refuse this additional use of your photos, and it is not mandatory to consent to any other photo usage to receive treatment.
Informed Consent:
This consent form is not meant to include all possible risks associated with a steroid injection, as there are both known and unknown side effects and complications associated with any medical treatment. We have written this consent form to ensure you are fully informed of the procedure, the reasons why you may not be able to receive treatment and the known risks of a steroid injection.
By signing this consent form, you acknowledge and confirm the following:
Risks and complications
You have discussed the potential risks and benefits of a steroid injection with your practitioner, and your questions have been answered satisfactorily.
You understand that medical attention may be required to resolve any complications associated with your treatment. In most cases, except those in an emergency, you should contact you practitioner for advice/treatment.
Medical History
To the best of your knowledge, you have provided the details of your past medical history and will inform your practitioner if this changes before any future treatments.
You understand that withholding aspects of your medical history could lead to serious physical and mental harm.
Contraindications & Cautions
You are not pregnant or possibly pregnant, lactating or nursing, and you will inform your practitioner if this changes before any future treatments.
Fees & Charges
You understand and agree that all services rendered will be charged directly to you, and you are personally responsible for payment.
You further agree, in the event of non-payment, to bear the cost of collection, court costs and reasonable legal fees, should they be required.
Refunds
Fees charged for treatment are for the delivery of a treatment and the accompanying service, which is inclusive of the following;
-Consultation and assessment
-The provision of information and advice
-The provision of the treatment itself, as described above
-Follow-up appointments and aftercare advice and support as appropriate
Whilst we undertake to provide excellent service, factual, honest and ethical advice, safe, expert treatment in experienced hands and only the best products, we cannot guarantee your results and cannot offer refunds if the results achieved fail to meet your expectations. The successful outcome varies by degree, and how long these effects last varies from one individual to another and cannot be guaranteed.
You understand that whilst you have been advised of a probable result, this should not be interpreted as a guarantee.
You will contact your practitioner if you are unsatisfied with your treatment outcomes.
Aftercare
You have verbally discussed the aftercare required following a steroid injection and have been informed that you will also receive this via email. You understand the importance of following the post-treatment advice and agree to follow it.
You understand that failure to follow this advice could lead to serious physical and mental harm.
Photograph Use Consent:
You understand that receiving treatment at Lumiere Medispa requires photographs to be taken of the treatment area. These photographs may be taken before, during, and after each treatment and will form part of your legal medical record at Lumiere Medispa. By signing below, you freely give your consent for your photos to be used solely for this medico-legal purpose. If we wish to use your photos for any other purpose, we will always seek separate written consent from you, and you have the right to refuse.
Valid Consent
By signing below, you acknowledge that you have read and understood this consent form and have had the opportunity to discuss any questions you have with your practitioner to your satisfaction. You consent to receive a steroid injection treatment under the terms of this consent form and understand that you have the right not to consent to this treatment and that your consent is voluntary.
