The purpose of this informed consent form is to provide written information regarding the risk, benefits and alternatives of the procedure named above. This material serves as a supplement to the discussion you have with me. It is important that you fully fully understand this service information, so please read this document if you have any questions regarding this procedure ask me prior to signing this consent for/intake form.

Treatment with dermal fillers, such as revolax, dermalax, and others 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. facial rejuvenation can be carried out with minimal complication. These dermal fillers are administered using a hyaluronic pen (non needle method). This produces natural appearing volume under wrinkles and folds, which are lifted up and smooth out. The results can often be seen immediately.

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 and risks that are not included on this list. Some of these risks, if they occur,may necessitate hospitalization, andor extended outpatient therapy to permit etiquette treatment. It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedures 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 piercing of the skin 3- allergic reaction 4- reactivation of herbs (cold sores)5- lumpiness, visible, yellow or white patches, 6- granuloma formation 7-  localized, necrosis, and or sloughing with scab and/or without scab if blood vessels occlusion occurs.

* non-treatable epilepsy

* inflammation, or infection in the lip area

* the tendency to develop hypertrophic scarring

* known hypersensitivity to hyaluronic acid

* non-hypersensitivity to lidocaine or local anesthetic from the amide group

* porphyria 

* diabetes 

* autoimmune disease 

* pregnant 

* currently being treated with anticoagulants, blood, thinners, aspirin, etc.

* blood diseases in blood coagulation problems

* malignant tumors

* under the age of 18 years old

* have any cold sores in the area

* have any trauma cuts, abrasions, infections, etc. in the area

* sunburn to the area

* severe skin conditions

 

Any medication or health conditions (including skin conditions)are to be written here and discussed with the practitioner

I am not aware that I am pregnant. I am not trying to get pregnant. I am not 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 did not have multiple allergies or high sensitivity to medication's, including but not limited to lidocaine 

Alternatives to the procedures, and options that I have volunteered for, have been fully explained to me

I understand that I have the right to discontinue treatment at any time.

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. It's affecting us up to six months or more. Most patients are pleased with the results of dermal filler use however, like any esthetic 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 dermal filler procedure is temporary and additional treatment will be required periodically generally within 4 to 6 months, involving additional treatments for the effect to continue I am aware that follow up treatments will be needed to maintain the full effects.

I am aware, the duration of the treatment is dependent on many factors, including but not limited to: age,sex,tissue conditions, my general health and lifestyle conditions ,and sun exposure. The correction, depending on these factors may last up to six months, and in some cases shorter in some cases longer I have been instructed in and understand the post treatment instructions.

I understand this is an elective procedure and I hereby voluntarily consent to treatment with dermal fillers for facial rejuvenation lip enhancement, establish proper lip and smile lines, and replacing facial volume. The procedure has been fully explain to me. I also understand that any treatment performed is between me and the aesthetic therapist who is treating me, and I will direct all post operative questions or concerns to the therapist. I have read the above and understand it. my questions have been answered satisfactorily. I accept the risks and complications of the procedure, and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history, I will notify the doctor healthcare professional who treated me immediately. I also state that I read and write in English. 

BY SIGNING THIS FORM, THE CLIENT CONFIRMS THAT THEY HAVE BEEN GIVEN A COPY AND UNDERSTOOD ALL THE INFORMATION GIVEN VERBALLY AND ON THIS FORM AND AGREE THAT THEY HAVE DISCLOSE (BY WRITING THEM ON THIS FORM) ANY HEALTH MEDICATION OR SKIN CONDITIONS WITH THE PRACTITIONER TECHNICIAN, AND THEY ARE HAPPY TO GO AHEAD WITH THEIR TREATMENT.