Restylane, Juvéderm, RHA (Hyaluronic Acid Injections)

INTRODUCTION

Hyaluronic acids include a wide range of complex carbohydrate molecules, normally found in the human body. Injection of hyaluronic acid (HA) into the skin or just below the skin can elevate depressed areas and wrinkles, and can provide a volume supplement to tissues to improve contours, such as lip and cheek enlargement. The effect of HA is not permanent and will last anywhere from 3 to 24 months, depending on the product chosen, as well as location, site and of depth of use. HA may not eliminate all types of wrinkles

INSTRUCTIONS 

This is an informed consent document to help you understand Hyaluronic Acid Injections, their risks, likely effects and alternative treatments. You have a right to be infrmed about your condition and its treatment, so that you may decide whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is  not meant to scare or alarm you; it is simply an effort to make you better informed so you may give, or withhold, your consent for treatment.

ALTERNATIVE TREATMENTS

Other “filler” materials exist that have similar effects such as collagen, fat grafts, Sculptra and Radiesse. Also, laser resurfacing and chemical peels can improve certain wrinkles. Certain deeper wrinkles may require surgical treatments, such as brow or face lifts.

POSSIBLE SIDE EFFECTS 

Every procedure involves a certain amount of risk and it is important that you understand these risks and the possible complications associated with them. In addition, every procedure has limitations. An individual’s choice to undergo this procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience the following, you should discuss each of them with your physician to make sure you understand the risks, potential complications, limitations, and consequences of injections. 

Allergic reaction or infection, bleeding, tenderness or pain, redness, bruising, scarring,lumps, bumps or swelling at the injection site.

Vascular occlusion is a rare but serious complication that can occur when dermal fillers are injected into a blood vessel or near one. This can happen when the filler material accidentally blocks blood flow, which can lead to tissue damage and necrosis.
Signs of a vascular occlusion include:
     -Intense pain that's not typical for lip fillers
     -Skin discoloration, such as blanching, duskiness, or other changes
     -Changes in skin texture, like thickening or firmness
     -Abnormal swelling or bruising
     -Lips that feel cold to the touch
     -Pallor, especially in the lips
     -A grey patch on the lip that doesn't refill with capillaries

Vascular occlusion may be evident at the time of the procedure or it can present itself a few days after treatment.  Early diagnosis and treatment can help improve blood flow and remove the blockage. If left untreated, a vascular occlusion can lead to skin necrosis, tissue death, and even blindness.

1. People with a history of cold sores may experience a recurrence after the treatment, although this can be minimized by the use of antiviral medicines. I agree to consult with Beauty Marx if I have a history of cold sores or fever blisters prior to this treatment.

2. I have advised Beauty Marx if I have severe allergies, particularly allergies to bacterial proteins. If I have an allergy to bacterial proteins I understand I am not a candidate for this treatment. I have also advised Beauty Marx if I have asthma, hayfever, eczema or a history of multiple allergies as any of these issues may increase my risk of allergic reaction.

3. I  understand the Post-Treatment Instructions. I agree to follow these instructions carefully. I understand that compliance with recommended pre- and post- procedure guidelines are crucial for healing, prevention of side effects and complications as listed above.

4. I have advised Beauty Marx if I am pregnant, trying to get pregnant or if I am nursing.

5. I have informed Beauty Marx of any dental work I have had including dental cleaning 30 days prior to any lip injections as well as planned dental procedures 30 days after lip injections.

6. I have provided Beauty Marx with a complete medical history and I do not suffer from any autoimmune diseases such as  lupus, rheumatoid arthritis etc. 

1. I HEREBY AUTHORIZE  Beauty Marx Aesthetics to perform the following procedure or treatment: ​Hyaluronic Acid Injection

2. I release all medical staff and specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.

3. I acknowledge that no guarantee has been given by anyone as to the results that may be obtained.

4. I consent to the photographing of procedure(s) to be performed, including appropriate portions of my body, for medical, social media, or educational purposes, provided my identity is not revealed by the pictures.

5. It has been explained to me in a way that I understand:

   a. The above treatment or procedure to be undertaken.

   b. There may be alternative procedures or methods of treatment.

   c. There are risks to the procedure or treatment proposed.

6. In the event it has been determined that a vascular occlusion has occured. I voluntarily consent to a hyaluronidase treatment.

I understand that no guarantee can be made as to the result of treatment and that hyaluronidase use for filler corrections is an off-label non-approved use. 

I confirm that in order to undergo said treatment, I accept the following preconditions. Beauty Marx Aesthetic MedSpa, providers and medical staff cannot be responsible for any results of treatment form any other physician or provider.

I will not hold Beauty Marx, Suzanne Munshower, RN or medical staff legally or financially responsible for anything resulting from the treatment that I deem unsatisfactory.

I will not hold Beauty Marx, Suzanne Munshower, RN or medical staff financially or legally responsible for any current or prior treatment.

I acknowledge and accept that I have been informed fully that results are not guaranteed and vary from person to person.

I acknowlege that  the procedure has been explained in detail and am fully aware of all the possible outcomes and/or side effects (bruising, swelling, pain, possibility of lumpiness or irregularity in the contour of treated area(s) and/or textural changes to the skin that may last for weeks). 

I understand and accept the above and enter into this agreement willingly and voluntarily. I understand that any treatment provided may or may not meet my expectations.

I understand and agree that there is no compensation or refund of monies paid in any event.

I consent to the taking of photographs and authorize anonymous use for the purposes of medical audit, education and promotion.

*All prices are subject to change without prior notice*

I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS. I AM SATISFIED WITH THE EXPLANATION.