INTRODUCTION

Radiesse Dermal Filler is a resorbable implant product approved by the United States Food and Drug Administration for the correction of moderate to severe facial wrinkles and folds, such as nasolabial folds. Radiesse injections are implanted intradermally through a fine gauge needle into the treated area.Radiesse is comprised of calcium hydroxylapatite (CaHA) microspheres.Radiesse dermal filler has been FDA approved for use in cosmetic treatments.

INSTRUCTIONS 

This is an informed consent document to help you understand Radiesse Dermal Filler injections, the risks, likely effects and alternative treatments. You have a right to be informed 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. 

1. Allergic reaction or infection, bleeding, tenderness or pain, redness, bruising, scarring,lumps, bumps or swelling at the injection site.
2. 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.
3. I am aware that a topical or local anesthetic may be used by my provider to alleviate pain and discomfort. I will advise my provider if I have any allergies to any sort.
4. I understand that multiple treatments are necessary to achieve desired results. Treatments generally last from 12-18 months. Touch up treatments may be necessary to maintain desired results. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. Clinical results vary per patient. I agree to adhere to all safety precautions and regulations during the treatment.  No refund will be given for treatments received. 
5. I understand if I have a history of keloid formation or hypertrophic scarring I must advise Beauty Marx and I am aware that I may not be eligible for this treatment.
6. If I currently take any blood thinners such as ibuprofen, aspirin, or herbal preparations prior to my procedure I will advise Beauty Marx . I understand the use of these medications may increase my risk of bruising.
7. I understand that Radiesse will not correct the underlying cause of facial fat loss but will improve the appearance in the treated area.
8. Microspheres in Radiesse can be seen in X-Rays and CT Scans. I understand I must inform my doctor and other health professionals that I have received Radiesse injections.
9. I understand the Post Treatment Instructions. I agree to follow these instruction carefully. I understand that compliance with recommended pre and post guidelines are crucial for healing, prevention of side effects and complications as listed above.
10. 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.
11. I have advised Beauty Marx if I am pregnant, trying to get pregnant or if I am nursing.

 

Consent to Treatment

1. I HEREBY AUTHORIZE  Beauty Marx Aesthetics to perform the following procedure or treatment: ​Radiesse Dermal Filler

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.

*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.