CONSENT FOR HYAPEN DERMAL FILLERS (HA)
I hereby authorize and direct the injection of hyaluronic acid dermal filler and/or Juvederm to me. Filler is a sterile substance consisting of stabilized hyaluronic acid and/or calcium hydroxylapatite. The manufacturers state that it is biodegradable, safely and completely metabolized by the body. Filler injections are given to correct wrinkles, volume loss and for augmentation and is approved by the FDA. I understand that the safety and effectiveness of treating certain areas has not been studied, however filler has been used to enhance appearance in over 60 countries. The off-label aspect of filler has been explained to me.
Alternative Treatments: There are alternatives to filler, including no treatment, cosmetics, neuromodulators, laser skin resurfacing, chemical peels, or surgery for wrinkle reduction.
Results: I understand that the actual degree of improvement cannot be predicted or guaranteed. Furthermore, I understand that the effect will gradually wear off and additional treatments may be necessary to maintain the desired effect.
Side Effects and Possible Complications: (can include but are not limited to)
· Potential allergic reaction. As with any product, allergies can develop during or after injection.
· Injection site reactions, a lumpy or thick feeling at or just under the skin, bruising, redness, itching, pain, tenderness or slight swelling.
· Injections into the lip area could trigger a recurrence of cold sores (Herpes simplex) for patients with a history of previous cold sores.
Precautions and Contraindications:
· Due to the potential for an allergic reaction, filler is not recommended for patients with a history of severe allergies or a history of anaphylaxis.
· The risk of bruising or bleeding may be increased by medications with anticoagulant effects, such as Aspirin, and non-steroidal anti-inflammatories. Advil, Motrin, Aleve, high doses of Vitamin E and certain herbs and supplements.
· Microspheres in Juvaderm can be seen in X-rays and CT Scans.
ACKNOWLEDGEMENT: I understand and acknowledge that payments for the above procedure are non-refundable and due at the time of service.
I understand the need for topical anesthesia may be necessary to reduce the discomfort of the procedure and consent to the application of a topical or injectable anesthetic By my signature below, I certify that I have read and fully understand the content of this consent form for the filler procedure and that the disclosures referred to herein were made to me. I release the injector, The Beauty Bar, and all staff from liability associated with this procedure and future filler injections.
· I am not pregnant and I am not breastfeeding.
· I understand and consent to photos for before and after comparisons.
· I have been given the opportunity to ask questions and my questions have been answered to my satisfaction.
· I agree to follow all post treatment instructions carefully and understand that these guidelines are crucial for healing, prevention of side effects and complications.
I have been informed of the risks and benefits of this treatment and wish to proceed with the treatment.