(Juvederm®, Voluma®, Restylane®, Belotero®,
Volbella®, Vollure®, Defyne®, Refyne®, Lyft®, Versa®)
The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure named above. This material serves as a supplement to the discussion you have with your doctor/healthcare provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form.
Treatment with dermal fillers (such as Juvederm®, Voluma®, Restylane®, Belotero®, Volbella®, Vollure®, Defyne®, Refyne®, Lyft® and Versa®) can smooth out facial folds and wrinkles, add volume to the lips, and contour facial features that have lost their volume and fullness due to aging, sun exposure, illness, etc. These injectable gels are a colorless hyaluronic acid, which is a naturally occurring sugar found in the human body. The role of the hyaluronic acid in the skin is to deliver nutrients, hydrate the skin by holding water, and to act as a cushioning agent. Facial rejuvenation can be carried out with minimal complications. These dermal fillers are injected under the skin with a very fine needle. This produces natural appearing volume under wrinkles and folds, which are lifted and smoothed out. The results can often be seen immediately.
RISKS AND COMPLICATIONS
Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks, some of which may not included on this list. Some of these risks, if they occur, may necessitate hospitalization, and/or extended outpatient therapy to permit adequate treatment. It has been explained to me that there are certain inherent and potential risks and side effects in any injection procedure and in this specific instance such risks include but are not limited to: 1) Post treatment discomfort, swelling, redness, bruising, and discoloration; 2) Post treatment infection associated with any transcutaneous injection; 3) Allergic reaction; 4) Reactivation of herpes (cold sores); 5) Lumpiness, visible yellow or white patches; 6) Granuloma formation; 7) Localized necrosis and/or skin sloughing, with scab and/or without scab if blood vessel occlusion occurs.
BRUISING AND BLEEDING
Patients who are using substances that can prolong bleeding, such as aspirin or ibuprofen, as with any injection, may experience increased bruising or bleeding at injection site. I will inform my physician prior to treatment if I am using any of these substances.
PREGNANCY AND ALLERGIES
I am not aware that I am pregnant, trying to get pregnant or lactating (nursing). I do not have or have not had any major illnesses which would prohibit me from receiving dermal fillers. I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to lidocaine.
Alternatives treatments for dermal soft tissue augmentation include bovine-based collagen and other, non hyaluronic acid-based, dermal fillers. Aside from these treatments, additional options for the correction of lines and wrinkles do exist, including facial creams, BOTOX® Cosmetic (botulinum toxin type A), chemical peels, and laser skin surface treatments. These may be discussed with your physician.
I understand that this is an "elective” procedure and that payment is my responsibility and is expected at the time of treatment.
I understand that correction is temporary; therefore touch-up injections as well as repeat injections are usually needed to maintain optimal correction.
I am aware that the injections may cause some discomfort during the injection. Physicians may choose to numb (anesthetize) the treatment area to further minimize discomfort.
I consent to be photographed before, during and after the treatment. These photographs shall be the property of Westside Aesthetics. These photographs may be published in scientific journals, shown for scientific reasons, and/or used in patient education and promotions both in and out of the office.
Dermal fillers have been shown to be safe and effective when compared to collagen skin implants and related products to fill in wrinkles, lines and folds in the skin on the face. Effects can last up to 1.5 years, depending on the filler that is used. Most patients are pleased with the results of dermal fillers. However, like any aesthetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatment to achieve the results you seek. The duration of treatment is dependent on many factors including but not limited to: age, sex, tissue conditions, general health and life style conditions, and sun exposure. I have been instructed in and understand the post-treatment instructions.