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Microsoft word - emla disclaimer.docx

Emla Disclaimer
Emla cream contains two medicines called Lidocaine and Prilocaine. These belong to medicines called
local anaesthetics. Emla cream works by numbing the surface of the skin for a short time. It is put on the
skin before certain procedures which can feel uncomfortable; this helps to stop or relieves the pain on
the skin. You cannot have Emla cream allied id you are allergic or hypersensitive to Lidocaine or
procaine or any of the ingredients listed below.

Emla cannot be used on babies aged 0-12 months who are being treated with medicines called
‘sulphonamides’ such as sulfamethoxazole

Are you anaemic
Do you have any blood condition where you have reduced red blood cells
A rare blood disease called glucose 6 phosphate dehdrogenase deficiency
Blood pigment level changes called ‘ methamoglobinaemia
Atrophic dermatitis(this condition means the skin does not need as much time to anesthetise )
Have you used medicines called?
Sulphonamides
Sulfamthoxazole
Other local anaesthetics
Medicines to treat uneven heart beats such as mexiletine or amiodarone
If you are pregnant or breast feeding you must consult your doctor before having Emla cream applied, as
the cream can pass into the breast milk. Emla can have side effects, these include:

Rash
Feeling short of breath
Low blood pressure, which may make you feel faint or dizzy
Swelling on the face, lips tongue or other parts of the body
Bluish gray skin in children, which is a very rare effect – due to lack of oxygen – if this happens
the cream must be removed and seek your doctors advise
Pale skin where the cream has been used
Mild itching or burning
Small red dots where the cream is applied
Emla cream 5% contains the following:
Active substances Lidocaine and Prilocaine, each gram contains 25mg Lidocaine and 25mg
Prilocaine
Polyoxyethylene hydrogenated castor oil
Carbomer 974P
Sodium Hydroxide
Purified water sign to state I have read and fully understood all of the above. I state I have no
known allergies or any of the listed above health problems or using any of the above
medications, or any such medications of the same type. I understand that I may have a reaction
and that I am not holding Profiles responsible, as they have taken all precautions for my safety,
any creams administered are at my own risk.

Signed_____________________________________________________________________
Date ______________________________________________________________________
Name (block) ________________________________________________________________
Address ____________________________________________________________________
Tel Numbers ________________________________________________________________
Therapist comments and signatures

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Source: http://www.profilesbeauty.com/disclaimers/Emla%20Disclaimer/Emla%20Disclaimer.pdf

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