Face It

Patient Name*

A dermal filler is usually a gel of hyaluronic acid generated by streptococcus species of bacteria chemically cross linked with BDDE, Stabilized and suspended in physiologic buffer at PH-7 and concentration of 20mg/ml. Areas most frequently treated are: nasolabial folds, oral commissures, lips and glabellar. Individuals may experience a slight burning sensation during injections. The procedure generally takes 20 to 30 minutes. Results may last 6 months. I understand that a dental infiltrate may be performed to provide temporary relief of discomfort associated with the administration of the dermal filler. I understand that dental infiltrates may not reduce all pain associated with the procedure.

Potential Risks and Side Effects
It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include, but are not limited to:

Post-treatment discomfort, swelling, redness, and bruising: Initial Here* .

Post-treatment bacterial, viral, and/or fungal infection requiring further treatment: Initial Here*.

Allergic reaction: Initial Here* .

Dental infiltrate risks including bleeding, infection, and adverse reaction to the anesthetic: Initial Here* .

Proposed Treatment Result
The practice of medicine and surgery is not an exact science and therefore reputable practitioners cannot guarantee results. While the overwhelming number of patients have gratifying results from dermal fillers, we cannot promise or guarantee specific results. In a very small number of individuals, the injection does not work as satisfactorily or for as long as usual. I do not have any hypersensitivity to any local anesthetic agents, nor do I have a history of malignant hyperthermia. I consent to photographs being taken to evaluate treatment effectiveness, for medical education, training, professional publications or sales purposes. No photographs revealing my identity will be used without my written consent. If my identity is not revealed, photographs may be used and displayed publicly without my permission.

Informed Consent

By signing below, I acknowledge that I have read the foregoing information and understand the risks of dermal filers and dental infiltrates. I voluntarily consent and authorize that this treatment be performed by the healthcare providers of Face it. I hereby release staff and any other participating healthcare providers from any and all liability for any adverse effects that may result from this treatment and related procedures. I hereby consent to treatment.

Patient Signature*

Date

Medical Staff Signature (MD,PA,APRN,RN)

Date

Dermal Fillers Treatment Consent Form