Thank you for your interest in the Hyaluronic Pen Treatment. This form is intended to provide you the information you need in order to make informed decisions about the treatment. Please read through below and fill out the information required to express your intention in undergoing the treatment.
Hyaluronic Acid treatments involve injecting purified Hyaluronic Acid into the skin. This fills the wrinkles and restores volume. Hyaluronic acid is naturally produced by your body that keeps your skin well lubricated and moist. We lose this as we age. This treatment is intended to retain Hyaluronic acid in our skin. But, just like natural Hyaluronic Acid, the injectables eventually lose their form and wears down in due time. The injectable Hyaluronic Acid can last around 6 months or longer. But since this is not permanent, a periodic treatment may be required for body retention.
PATIENTS THAT MAY NOT BE ELIGIBLE FOR THE TREATMENT
Due to certain health conditions, some may not be allowed or may be evaluated further to take this treatment. This is for the protection of the health and safety of the patient. We have enumerated here the following conditions that may prevent the patient to undergo the Hyaluronic Acid treatment and thus the injector must be notified:
The following are the possible risks that Hyaluronic Acid treatment may cause (please check each item as an express of your acknowledgment to the risk):
I read and fully understand the risks mentioned above, as well as other risks which may not fully be known. Nonetheless, I understand and assume all the risks involved in the treatment. I release, waive, and forever discharge the clinic, its employees, staff, directors, partners, and affiliates from any or all injuries, damages, or death that may occur during or after treatment that may be caused by said treatment.
I declare that I am of legal age with the full legal capacity to execute and bind myself to this consent. I have had the opportunity to ask questions that are unclear to me and answers were given to me by the clinic's representative to my satisfaction.
By signing this form, I give my consent in full consideration and understanding without any representation, coercion, or inducement.