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Injectable Filler Consent

CONSENT FOR TREATMENT WITH INJECTABLE FILLER

The use, indications, contraindications, and potential adverse effects of treatment with injectable fillers have been explained to me in a way that I understand. I have answered all questions regarding my medical history truthfully. I have discussed the risks and benefits of injectable fillers with the treating physician and/or his assigned healthcare professional and have received satisfactory answers.

I understand that:

         The proposed product(s) are composed of hyaluronic acid of non-animal origin.

         The product is injected to temporarily improve the appearance of wrinkles, lines, folds, or contours of my face.

         The effects last approximately 12 to 18 months, but varies based on the amount and type of product, location of injection, and inter-personal variation. In the lips, the effect may last 4 to 6 months.

         A touch-up procedure a few weeks after the initial injection may be indicated.

         Topical and/or injectable local anesthetic may be administered by my healthcare professional.

         No guarantee has been made regarding the cosmetic outcome of this procedure.

         Photographs may be taken before and after the treatment for my medical record.

I understand that there are potential adverse effects of injection, including but not limited to:

         Inflammatory reactions such as redness, swelling, and/or discomfort such as stinging, pain or pressure.

         Swelling or nodules at the injection site.

         Bruising or bleeding at the injection site which is worsened by the use of aspirin, ibuprofen, or related products within 2 weeks before and 1 day after the injection.

         Asymmetry, minor irregularities, or inadequate cosmetic results.

         Very rarely discolouration at the injection site.

         Very rarely necrosis, granuloma, abscess, or infection.

         Persistence of any inflammatory reactions after 1 week should be reported to my physician.

I have informed my physician and/or assigned healthcare professional of my medical history and recognize that I should not be treated with injectable filler products:

         If I am pregnant or breast feeding.

         In areas with inflammatory of infectious skin problems (eg. Acne).

         If I have autoimmune disease or immune suppression.

         If I have known sensitivity to hyaluronic acid.

         If I am undergoing laser, chemical, or dermabrasion skin treatment.

         If I have a predisposition to keloid scar formation.

I have read the above information and have discussed the risks and benefits of this procedure to my satisfaction with my physician and/or assigned healthcare professional.

I recognize that not having this procedure is an option.

I recognize that this is a cosmetic procedure and that there is an associated fee.