Consent Form - Filler

Consent Form - Filler
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Email
example@example.com
Information

Please read each point carefully and acknowledge your consent with an electronic signature in the space provided below.
1. Dermal filler, also known as "filler", is a special medical gel made of a naturally occurring substance called hyaluronic acid (HA). There are several different brands which are almost identical (Juvaderm, Restylane, Princess). The treatment is approved and save when prescribed by a doctor. *

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2. The effects of the treatment will be noticeable immediately, but there is a limit to how much filler it is reasonable to do at one time, so it may take more than one treatment session to achieve the look you are after. The effect of the filler will usually last from 3-12 months depending on the area treated. After that time the product is naturally degraded by your body. *

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3. The aim of our therapy is to use subtle amounts of dermal filler to create a natural, fresher, more youthful look, without limiting your ability to express yourself. We will not eliminate all signs fo ageing, instead aiming to produce a soft, rested face. Ideally, no-one will know we were there! *

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4. We will consult with you about where you feel treatment would benefit you most, and offer our recommendation/s. Each treatment will be tailored to your individual needs. Prices are per unit of dermal filler, and the amount required may vary. We will always discuss and agree a plan with you before proceeding. *

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5. The procedure will involve several injections with a very fine needle in the areas discussed in your treatment plan. You may feel some slight discomfort but it is usually not painful. It will take about 30 minutes of sitting comfortably. *

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6. You should not apply makeup to the treated areas for 12 hours afterwards, and you should avoid massaging or otherwise putting pressure on the treated area for 48 hours afterwards (if possible, try to sleep on your back). You should also avoid prolonged exposure to extremes of heat, cold, or UV light for 2 weeks (a sauna, for example). *

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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.
*

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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.
Signature *

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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.
I consent for my photograph to be taken for the purposes of clinical review. Please leave blank if you DO NOT give permission for your photos to be taken.

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Office Use Only:

Injector: blanks
Prescribing doctor: blank
Should be Empty:

Consent Form - Filler

Information

CONSENT