Botox/Dysport and Dermal Filler Injections Informed Consent
This informed consent document that has been prepared to help inform you concerning BOTOX/Dysport and Dermal Filler injections, their potential side effects and risks, and alternative treatment(s).
* Please read this information carefully, completely and discuss any questions you may have with your provider. Once you have read and understand this information, please sign and date this consent. BOTOX/Dysport involve a series of small subcutaneous or intramuscular injections designed to weaken certain muscles that cause skin wrinkling. Weakening of the injected muscles begins to be apparent after 2-3 days with the peak effect being reached after 14 days. Results can last 2-5 months. The procedure can be repeated every 3-4 months; however, injections given at less than 3 month intervals may not produce a noticeable effect. This product is FDA approved for the glabella region, and injection into any other areas at this time is considered “offlabel” use. Dermal Filler Injections (i.e. Restylane, Juvederm, Voluma, Radiesse) are used to smooth moderate to severe facial wrinkles and folds around the nose and mouth or shape facial contours. The fillers used have been FDA approved for the cosmetic treatment of moderate to severe facial wrinkles and soft tissue depressions. Normal occurrences during BOTOX/Dysport and Dermal Filler Injections may include bleeding and bruising, swelling, skin redness, needle marks, acne-like skin eruptions, skin lumpiness, visible tissue filler material, asymmetry, pain, and skin sensitivity. Alternative Treatments Alternative forms of non-surgical management for the appearance of wrinkling and lines in the skin include laser procedures, chemical peels, micro-needling and microdermabrasion. Alternative forms of treatments are all associated with certain risks. Risks Every procedure involves a certain amount of risk, and it is important that you understand the risks involved. An individual’s choice to undergo a procedure is based on the comparison of the risk to the potential benefit. Although the majority of patients do not experience these complications, you should discuss each of them with your provider to make sure you understand the risks, potential complications, and consequences of BOTOX/Dysport or Dermal Filler Injections. Although good results are expected, there cannot be any guarantee or warranty expressed or implied with regard to the results that may be obtained.
-Risks of Botox/Dysport Injections may include the following: Bleeding, bruising, infection, unsatisfactory results, and allergic reactions (in rare cases, local allergies to botulinum toxin A preparations have been reported. Systemic reactions, which are more serious, may result from any medications or substance used during the procedure), drooping of the eyelids (ptosis), and additional procedures. Should complications occur, other treatments may be necessary.
-Risks of Dermal Filler Injections may include the following: Bleeding, bruising, damage to deeper structures, infection, skin necrosis, allergic reactions and hypersensitivity, scarring, granulomas, skin disorders, antibodies to the filler product, accidental intra-arterial injection, nerve injury, numbness, tingling, blindness, under/over correction, migration of filler product, unsatisfactory result, and long-term effects. In rare cases, injection of dissolving agent may be necessary to improve or correct complications.
Photographs Photographs may be taken before and after treatments in order to monitor progression. ___I consent to the usage of such photographs provided the pictures do not reveal my identity.
Informed consent
I acknowledge that I have read and understand the information for BOTOX / Dysport / Dermal Filler Injections. I feel I have been adequately informed of the risks of BOTOX / Dysport / Dermal Filler Injections as well as alternate methods of treatment.
All of my questions have been addressed and answered to my satisfaction. I agree to the terms of this agreement. With this in mind, I hereby consent to BOTOX / Dysport / Dermal Filler Injections Treatment, performed by Upland Med Spa and such assistants. *Attention* clients any treatments done in our medical spa are non- refundable. If there are any questions or concerns please contact management staff. We advise you have two weeks post-op treatement from your appointment to receive a Touch up for any inconveince. Office and Staff is no longer responsible past the Two week due date.