• Consent Form - Filler

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  • Information

    Please read each point carefully and acknowledge your consent with an electronic signature in the space provided below.
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  • CONSENT

    When used by qualified staff for cosmetic therapy, dermal fillers are very safe, and are typically very well tolerated.
  • I understand that people who should NOT receive dermal filler treatments include:

    1. People who have previously had a reaction to dermal filler or who have an allergy to lignocaine

    2. People who are pregnant or breastfeeding

    3. People who form keloid scars

    4. People who have an infection at the proposed site of injection

    5. People who are taking anti-coagulation (blood thinning) medication

    and that I do not suffer from any of the above conditions.

  • Clear
  • I understand that there are FOUR major risks to be aware of:

    1. The treatment may not work as well as you would like. For example, the volume achieved by the filler may not be as much as you were hoping for. We will follow-up with you two weeks after your treatment to see how you are feeling about the effects.

    2. You may experience itching at the site of treatment, which usually resolves in a few days. Occasionally, you may notice some bumps underneath your skin, some redness, or some pimples. Again, these usually resolve after a few days.

    3. Bleeding, bruising, or infection, while unexpected, may develop at the injection site. Rarely, an infection may become complicated. If you suspect an infection has occurred, please let your doctor know by contacting your clinic.

    4. A rare but serious complication may occur if the filler blocks a blood vessel. This can cause a lack of blood flow to the areas 'downstream' of the blockage. Consequences of this can include skin discolouration or skin death. In a few cases worldwide, the blood vessels affecting the eye have been affected, causing blindness. Your nurse has special training, medication, and equipment to minimise the risk of blood vessel occlusion occurring.

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  • By signing here I indicate that none of the at-risk categories detailed above apply to me, and that I have read, understand, and accept the risks of the procedure outlined above. Any questions I have about the treatment have been encouraged and answered. I consent for the procedure to go ahead as discussed with my clinician.

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  • Photographs: As a normal part of cosmetic therapy, photographs are taken to gauge the effects of the treatment over time. Images are stored securely and are not used for any other purpose.

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  • Office Use Only:

    Injector:
    Prescribing doctor:

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