Dermal Filler Consent Form

Dermal Filler Consent Form
Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Are you currently taking any medication?
YesNo
Please, specify
As far as you know do you have any allergies?
YesNo
Please, specify
Have you had any treatment with dermal fillers before such as absorbable dermal fillers, semi permanent dermal fillers, or botulinum toxin?
YesNo
Please, specify
Are you pregnant or breast feeding?
YesNo
Please select if you you suffer from any of the conditions listed below
Auto-immune diseaseCutaneous (skin) infection or inflammatory problemsAcute rheumatic fever or recurrent sore throatEpilepsyHypertrophic scarringCardiac conduction disorders (heart rhythm problems etc.)Reacted to hyaluronic acid, amide type local anesthetics or lidocaineOther
Please, specify
Purpose of the Consent:
To provide written information regarding the risks, benefits, and alternatives of the Hyaluronic Acid Filler such as Restylane, Juvaderm, & Belotero. (Non-Animal Stabilized Hyaluronic Acid), this consent is written. It is important that the patient should fully understand the treatment priorly. Before signing the consent, the patient should ask any of the questions regarding the treatment, Hyaluronic Acid Filler, and procedures to their doctor or healthcare professional.
The Treatment Information:
All mammals have hyaluronic acid naturally and it contains several soft tissues. This acid can also be produced synthetically. Dermal Fillers use hyaluronic acid which is a non-animal product, so the risk of animal-based disease or allergy is low. To lessen the discomfort, the injections contain a local anesthetic. For lasting effects, the treatment should continue. After injection, the body absorbs dermal fillers slowly and the length of the effect depends on the person.
Risks and Side Effects:
The possible side effects are listed below. However, the patients should be aware that there may be unique effects to certain people that are not known right now.
Some possible occurrences during Tissue Filler Injections: Bleeding and Swelling,
Erythema (Skin Redness), Needle Marks, Acne-Like Skin Eruptions, Skin Lumpiness, Visible Tissue Filler Material, Asymmetry, Pain.
Risks of Dermal Filler Injections: Damage to Deeper Structures, Infection, Skin Necrosis, Allergic Reactions and Hypersensitivity, Scarring, Granulomas, Antibodies to Fillers, Accidental Intra-Arterial Injection, Under /Over Correction, Migration of Dermal-Fillers, Drug, and Local Anesthetic Reactions.
Limitations and Alternatives:
From time to time, there are cases that the treatment could not be successful or wears off quickly. Alternatives may include; laser treatments, chemical skin peels, other skin procedures, or alternative types of tissue fillers.
I agree with the following statements:
I have been given enough information about the treatment I am to receive and informed about the procedure. I got the detailed explanation of the procedure I am to undergo. I understand the aims and objectives of the treatment completely. They have given me the opportunity to ask all remaining questions I may have about the treatment, and I answered them to the best of their ability. Having considered all aspects, I have decided to have this treatment of my own accord with sole intention the anticipated benefit from the same, provided by my therapist performing the treatment procedure. I understand that I will not be able to sue my therapist in case of any complications or be entitled to a refund if I am not happy with my procedure.The alternative treatments are considered by me and I selected that Dermal Filler is the best one for me.I have given enough time to consider this treatment and I have answered a detailed medical history form above to the best of my knowledge.I agree to follow advices given to me after treatment.ACCORDING TO THE INFORMATION ABOVE, I AM GIVING CONSENT TO RECEIVE THE TREATMENT BY MY THERAPIST.
Date
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Date
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