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.

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