Hyaluron Pen Consent Form

INTRODUCTION

Hyaluronic Acid treatments involve injecting purified Hyaluronic Acid into the skin. This fills the wrinkles and restores volume. Hyaluronic acid is naturally produced by your body that keeps your skin well lubricated and moist. We lose this as we age. This treatment is intended to retain Hyaluronic acid in our skin. But, just like natural Hyaluronic Acid, the injectables eventually lose their form and wears down in due time. The injectable Hyaluronic Acid can last around 6 months or longer. But since this is not permanent, a periodic treatment may be required for body retention.

PATIENTS THAT MAY NOT BE ELIGIBLE FOR THE TREATMENT

Due to certain health conditions, some may not be allowed or may be evaluated further to take this treatment. This is for the protection of the health and safety of the patient. We have enumerated here the following conditions that may prevent the patient to undergo the Hyaluronic Acid treatment and thus the injector must be notified:
1. Those who had allergic reactions to hyaluronic products
2. Those who are anaphylactic or having a history of a serious allergic reaction
3. Those who are Keloid formers
4. Those who are pregnant or nursing a child
5. Those who recently had dental/facial surgery.
6. Those who have viral infections such as herpes or simplex (cold sores)
7. Those who are under medication
RISKS

The following are the possible risks that Hyaluronic Acid treatment may cause (please read and sign each item as an express of your acknowledgment to the risk):
I agree that I am 18 or older , am NOT under the influence of any drugs or alcohol, am NOT pregnant or nursing , and voluntarily elect to receive dermal filler through microneedle /and or needless service.*

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Itchiness, redness, and/or swelling at or around the injection may occur. This occurence is normal and happens immediately after treatment and will disappear after a few days or up to a week. Some patients may experience prolonged swelling and/or tenderness/pain at the injection site lasting up to several weeks. I understand that I might experience the statement above*

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Pain and tenderness at or around the treated area typically resolve within a few days to a week. I understand that I might experience this during or after treatment and I understand that this resolves typically from a few days up until a week*

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Persons taking medications have a higher risk of bruising and bleeding. I understand I may experience this statement *

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I understand that I might experience the statement above. I understand that this may require antibiotics. In any case, I shall notify the clinic should this happen
Alternatives to temporary fillers include, but are not limited to, permanent dermal fillers, laser resurfacing, surgical facelift, other laser procedures, or no treatment at all.

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I have been informed of the nature, risks, and possible complications and consequences of dermal filler injections. I understand that having dermal fillers injected may have known or unknown complications including but not limited to redness, swelling, bruising, and infection. Rare complications may include red bumps, pustules, skin discoloration, filler extrusion from the skin, visibly raised areas of the skin, lumpiness, granulomas, allergic reactions with itchiness, redness, and anaphylactic shock. Another serious and rare complication of dermal fillers is the risk of unintentionally injecting the filler into a blood vessel or overfilling the tissue which can block blood flow to the treated area or distant areas causing tissue damage and tissue death (necrosis). Blood vessel occlusion can result in blindness if the filler is injected into a blood vessel near the eye such as the tear trough or the frown area. Blood vessel occlusion can result in necrosis of the side of the nose or cheek if the filler is injected into a blood vessel near the nose or the fold between the cheek and the nose.*

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I understand that this may happen. In such occurrence, I might need to return for additional treatment for correction purposes.
I have received pre- and post-care instructions and I will strictly adhere to such instructions. I understand that my failure to properly follow pre and post-care instructions may compromise my procedure. I understand this procedure may be uncomfortable or slightly painful while being performed.*

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Please upload a picture of any identification to prove your age *

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I read and fully understand the risks mentioned above, as well as other risks which may not fully be known. Nonetheless, I understand and assume all the risks involved in the treatment. I release, waive, and forever discharge Katherine L (pretty and links) from any or all injuries, damages, or death that may occur during or after treatment that may be caused by said treatment.

I declare that I am of legal age with the full legal capacity to execute and bind myself to this consent. I have had the opportunity to ask questions that are unclear to me and answers were given to me by the representative to my satisfaction.

By signing this form, I give my consent in full consideration and understanding without any representation, coercion, or inducement.
Date

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
Instagram username *
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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