KEC Dermal Filler Consent

Possible side effects: 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.

BELOTERO Balance is an intradermal filler that replaces lost hyaluronic acid caused by the natural aging process. This soft cohesive gel quickly integrates into your skin for results that are instant.
JUVÉDERM®/Vollure®/Revanesse Versa® is a hyaluronic acid gel 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 hydroxyapatite, which is the same mineral your bones and teeth consist of, suspended in an aqueous gel carrier. The microspheres form 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 hyaluronic acid in the skin is to deliver nutrients, hydrate the skin by holding in water/moisture, and to act as a cushioning agent.

The potential benefits have been explained of fillers along with alternative methods.
I understand that compliance with pre and post care instructions is crucial for success of treatment and to prevent unnecessary side effects or complications.
I understand that 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.

Patient's Initials*

I understand that necessary 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.

Patient's Initials*

I DO or DO NOT consent to photographs and other audio-visual and graphic materials before, during and after the course of my treatments to be used for marketing and medical educational purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I may or may not be identified by the photos. *

I DOI DO NOT

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. I agree to the terms of this agreement.

Patient's Signature

Patient's Name*

First NameLast Name

Patient's Date of Birth*

Patient ID#

Date

Witness Signature

Witness Name

First NameLast Name

Physician's Signature: Nancy Chen, M.D.