• DERMAL FILLER INFORMED CONSENT

  • We are 100% committed to the health and well-being for everyone. We are doing everything we can to keep potential exposure out of our office.

    As part of the local and state guidelines you must answer no to all the following questions each time you enter Pua Manu MedSpa.

    Not present a fever over 100 F/ 37 C.
    Not presenting cold, cough, difficulty breathing muscle pain, headache,
    loss of taste/smell or pink eye in past 5 days.
    Not in contact with anyone with these symptoms in the past 5 days.
    Not in contact with anyone diagnosed with COVID-19, sick and quarantined, in the past 5 days.


    All information above is true. I may be asked again when I arrive for my appointment. 


    ALL PATIENTS AND STAFF ARE REQUIRED TO: 

    Stay home if you are sick or are exhibiting symptoms of illness such as a fever or persistent cough.
    Face mask are required to enter the Spa.
    Refrain from shaking hands or other touching rituals.
    Wash hands for 60 seconds with soap and warm water prior to treatment or use hand sanitizer.
    Refrain from eating or drinking while in the Spa, face mask should not be removed. 
    I understand that Pua Manu MedSpa has put in place reasonable safety measures to help reduce the spread of COVID-19.

    I understand that I am consenting to an elective treatment/procedure that is not urgent or emergent. I understand that it may put me at increased risk for becoming infected with COVID-19, due to potential community exposure.

  • Patient acceptance*

  • BELOTERA Balance ia an intradermal filler that replaces los hyaluronic acid caused by the natural aging process. This soft cohesive gel quickly intergrates into your skinfor results that are instant.

    JUVEDERM/VOLLURE/REVANESSE VERSA is a hyaluronic acid that is injected into facial tissue to smooth wrinkles and folds, especially around the nose and mouth.

    RADIESSE is a subdermal filler made up of biocompatible microspheres of calcium hydroxapatite, which is the same mineral your bones and teeth consist of, susspended in an aqueous gel carrier. The microspheres fprm a scaffold which stimulates the body to create new collagen around them.

    Hyaluronic acid is a naturally occurring sugar found in the human body. The role of the hyaluronic acid in the skin is to deliver nutrients, hydrate the skin by holding in water/moisture, and act as a cushioning agent.  

  • Side Effects and Complications include but are not limited to:

  • The most common side effects include, but are not limited to, temporary injection-site reactions such as redness, pain/tenderness, firmness, swelling, lumps/bumps, bruising, itching, and discoloration. Most side effects are mild to moderate in nature, and last 7 days or less (less than 14 days for lips). As with all skin injection procedures, there is a risk of infection.*
  • Dermal fillers should NOT be used in patients who have:• Severe allergies marked by a history of anaphylaxis or history or presence of multiple severe allergies• Patients with a history of allergies to Gram-positive bacterial proteins• Avoid touching the treated area for 6 hours following treatment, so you do not accidentally move the product or injure you skin while the area is numb. Choosing this procedure does not guarantee or give an assurance of successful results. Results vary from patient to patient depending upon the individual, product used, and activities done. Additional treatments should be administered BEFORE the results have completely dissipated.*
  • The potential benefits have been explained of fillers along with alternative methods. Compliance with pre and post care instructions is crucial for success of treatment and to prevent unnecessary side effects or complications. This is an elective procedure, that insurance does not cover this procedure, that I am solely responsible for payment, and there are no refunds for procedures. Fee structure and payment have been fully explained to me.*
  • Discounted or special priced treatments must be prepaid in full by first treatment appointment. Incomplete and/or cancelled treatments will be charged at regular/full price, NO refunds.*
  • I have read and understand all information presented to me before signing this consent form. I have been given an opportunity to have all of my questions answered to my satisfaction. I understand the procedure and accept the risks. I authorize Dr. Chen to perform filler treatment on me.
  • Photos will be taken before, during and after the course of my treatments for medical purposes and to evaluate treatment effectiveness. I understand that my photos will be kept confidential in my electronic patient record.*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
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