Dermal Fillers Informed Consent

Treatment with Dermal Fillers can smooth out folds and wrinkles, add volume to the lips, and contour facial features that have lost their fullness due to aging, sun exposure, weight loss, or illness, etc. Facial rejuvenation can be carried out with minimal complications. Dermal Fillers are injected into the skin with a very fine needle. The products produce a natural volume under the wrinkle, which is lifted up and smoothed out. The results can often be seen immediately. Treating wrinkles with Hyaluronic Acid Fillers (Revanesse, Restylane, Juvaderm) or Radiesse is safe and leaves no scars or other traces on the face.

RISKS AND COMPLICATIONS
It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure ab dub this specific instance such risks include but are not limited to: 1) Post treatment discomfort, swelling, redness and bruising, discoloration 2) Post treatment infection associated with any transcutaneous injection 3) Allergic reactions 4) Reactivation of Herpes (cold sores) 5) Depending on filler used lumpiness, visible yellow, white or light lavender patches 6) granulation formation7) Rarely, localized necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs.

Name

First Name Last Name

Date of Birth

Date

Phone Number

Area Code Phone Number

Email

example@example.com

Would you like to receive promotional emails from us?

Yes No

Are you currently, or is there a chance you are pregnant?

Yes No

Please list any MEDICATION ALLERGIES or adverse reactions

PREGNANCY ALLERGIES & DISEASE

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 this treatment. I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to lidocaine.

PAYMENT

I understand that this procedure is cosmetic and that payment is my responsibility.

RESULTS

I am aware that full correction is important, and that follow-up touch ups/treatments will be needed to maintain the full effects. I am aware that the duration of treatment is dependent on many factors including but not limited to: age, sex, tissue condition, my general health and lifestyle conditions, and sun exposure. The correction, depending on these factors may last 3-6 months and, in some cases, longer.

PHOTOGRAPHS: I authorize the taking of clinical photographs and their use for scientific, educational, social media, promotional purposes both in publications and presentations. I understand my identity will be protected. (please initial)

I have been instructed in and understand post treatment instructions and have been given a copy of them as well. (Initial here)

I hereby voluntarily consent to treatment. The procedure(s) has been explained to me. I have read the above and understand it. I understand that the dermal fillers used are FDA approved and that some areas for corrections which I have requested are considered off-label. Alternatives of no treatment were also discussed. My questions have been answered satisfactorily. I accept the risks and complications of the procedure. I fully understand that the health care professional who is administering the Dermal Filler is a practicing Physician, Nurse Practitioner or Physician Assistant. I affirm that I am over 18 years of age, am not under the influence of drugs or alcohol and consent to cosmetic treatment.

Date

Signature

Clear