Dermal Fillers® are a gel of hyaluronic acid generated by Streptococcus species of bacteria, chemically cross-linked with BDDE, stabilized and suspended in physiologic buffer at PH=7 and concentration of 20 mg/ml. Areas most frequently treated are: nasolabial folds, oral commissures, lips, and Glabellar.  The client may experience a slight burning sensation during injections. The procedure takes about 20-30 minutes.  Results last approximately six months.

RISKS AND COMPLICATIONS
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 : 1) Post treatment discomfort, swelling, redness, and bruising,  2) Post treatment bacterial, viral, and/or fungal infection requiring further treatment,  3) Allergic reaction 4) Injection into vessels leading to blindness or partial blindness 

PHOTOGRAPHS
I authorize the taking of clinical photographs and their use for scientific purposes both in publications and presentations.  I understand my identity will be protected.

PREGNANCY, ALLERGIES  
I am not aware that I am pregnant, have any significant Medical diseases, or have any severe allergies.

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

 
I hereby voluntarily consent to treatment with Dermal Fillers® injection for the condition known as Facial Static Wrinkles. The procedure has been explained to me.  I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure.