Dermal Filler Consent Form

Dermal Filler Consent Form
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What is being injected?

Hyaluronic acid injectables include branded products such as Juvederm, Restylane, Boletero, Profhilo and Stylage – these include in their make up water, hyaluronic acid, lidocaine anaesthetic, and stabilizing molecules.
What is it used for?

They are used to improve the appearance of wrinkles/lines, correct volume loss and alter proportions. They can treat deep skin depressions up to fine lines as well as improving skin quality in some cases. They can also be used for enhancement of features such as lips or cheeks.
How long does it last for?

Treatment with filler can last 6-24 months dependent on skin type, area treated, quantity of product used and lifestyle factors such as smoking and sun exposure.
Contraindications to Dermal Filler
- Pregnancy and breastfeeding
- Children
- History of hypersensitivity to ingredients
- History of auto immune or immune diseases including Type 1 DM, polyarthritis, rheumatoid arthritis, ankylosing spondylitis, psoriasis, thyroid disorder, scleroderma, inflammatory intestinal disease, lupus, multiple sclerosis, ulcerative colitis.
- Skin pathology (herpes, acne, rosacea) or unhealed skin lesions
- Previous injection of permanent products such as silicone
- Infection of dental origin (untreated or treated less than one week ago)
What are the potential adverse side effects?

Dermal filler is a widely tried and tested procedure with good results for the majority of people. There are however some side effects that can occur, from minimal to more severe.
- Bleeding, bruising or hematoma at injection site
- Infection post procedure causing undue redness and swelling
- Reaction to the product, either localized or, very rarely, anaphylaxis.
- Swelling, bumps or lumps – these are generally temporary and an unwanted residual asymmetry or swelling is treatable.
- Skin changes – there may rarely be pigment changes, formation of thread veins or other blemishes. These may resolve, require further treatment or be permanent.
- Blood vessel blockage – in very rare instances filler can block a blood vessel and cause necrosis (characterized by lack of blood flow to an area and severe pain). Seeking help immediately if you suspect this is essential.

CONSENT TO TREATMENT

CONSENT TO TREATMENT

I consent to being treated with Dermal Filler and having before and after photographs taken of this treatment. All photographs remain the property of Cosmic Clinics.

I hereby certify that I have been fully informed of the nature and purpose of the procedure including expected outcome and possible complications.

I understand that there can be no guarantee or assurance as to the final result that may be obtained. Subjective dissatisfaction may be a possible outcome regardless of effectiveness of treatment. All people are individual and a refund will not be given after treatment.

I understand adjustments may be needed which may incur a further charge.

I have been given the opportunity to ask questions and hereby certify that I have read and full understood the contents of this consent form.
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