Rationale

Treatment with dermal fillers can smooth out facial folds and wrinkles, add volume to the lips, and contour facial features that have lost their volume and fullness due to aging, sun exposure, illness, etc. Facial rejuvenation can be carried out with minimal complications. These dermal fillers are injected under the skin using a very fine needle or blunt tip cannula. This produces natural appearing volume under wrinkles and folds which are lifted up and smoothed out. The results can often be seen immediately.

RISKS AND COMPLICATIONS
Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization, and/or extend outpatient therapy to permit adequate treatment. It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include but are not limited to: Post treatment discomfort, swelling, redness, bruising, and discoloration; Post treatment infection associated with any transcutaneous injection; Allergic reactions; Reactivation of herpes (cold sores); Lumpiness, visible yellow or white
patches; Granuloma formation; Localized necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs; In very rare occasions, if occlusion of the retinal artery occurs, permanent blindness can result.

I agree to inform my treatment provider PRP Medical Aesthetics immediately if I notice any changes which may indicate an adverse reaction, including skin changes, bruising, pain, vision changes, loss of sensitivity, excess swelling, or any other concern.  The phone number for PRP Medical Aesthetics is 778-772-8711.

PREVIOUS COSMETIC PROCEDURES

I certify that I have fully and accurately disclosed all previous cosmetic treatments which I have received, including all cosmetic surgery procedures and any negative outcomes.  I understand that this is important so that any risks associated with this current treatment may be managed properly.

PREGNANCY AND ALLERGIES
I am not aware that I am pregnant, I am not trying to get pregnant, I am not lactating (nursing), I do not have or have not had any major illnesses which would prohibit me from receiving dermal fillers. I certify that I do not have
multiple allergies or high sensitivity to medications, including but not limited to lidocaine.

ALTERNATIVE PROCEDURES
Alternative procedures to dermal fillers for lines and wrinkles include laser treatment, other injections such as with platelet-rich plasma, radiofrequency devices, botox, or surgery.

PAYMENT
I understand that this is an “elective” procedure and that payment is my responsibility and I agree to pay the full cost at the time of treatment.

RESULTS
I understand that results cannot be guaranteed and like any aesthetic procedure, the results are temporary and full results may not be visible immediately.  In addition, follow up treatments may be recommended for to improve results.  Most patients are pleased with the results of dermal fillers use. Additional treatments may be required periodically, generally within 4-6 months and up to one year, involving additional injections for the effect to continue. I am aware that follow-up treatments will be needed to maintain the full effects. I am aware the duration of treatment is dependent on may factors but not limited to: age, sex, tissue conditions, my general health and life style conditions, and sun exposure. The correction, depending on these factors, may last up to 1 year and in some cases shorter and some longer. I have been instructed in and understand the post-treatment instructions.

I understand this is an elective procedure and I hereby voluntarily consent to treatment with dermal fillers for facial rejuvenation, lip enhancement, establish proper lip and smile lines, and replacing facial volume. The procedure has been fully explained to me. I also understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-operative questions or concerns to the treating clinician. I have read the above and understand that no guarantees are implied as to the outcome of the procedure.  I also certify that if I have any changes in my medical history I will notify the doctor/healthcare professional who treated me immediately. I also state that I read and write in English.