Treatment with Dermal Fillers can smooth out folds, wrinkles, facial creases, contour defects, depression scars, facial lipoatrophy. Your physician/practitioner will evaluate the area for treatment and determine the level of correction necessary to achieve the optimal result; this may involve using one to several syringes depending on the product and/or the depth of the wrinkles/folds. An anesthetic numbing medicine used to reduce the discomfort of the injection, may or may not be used. These Dermal Fillers are injected into the skin with a very fine needle. The products produce a natural volume under the wrinkle, which is lifted up and smoothed out. Often multiple injections are needed to achieve the best correction and the results can often be seen immediately. Since these filling agents are considered temporary, periodic touch-up injections are necessary to help sustain the desired level of correction.
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: 1) post treatment discomfort, swelling, redness, lumpiness, and bruising which generally subside within a few hours to days (bruising may last up to 2 weeks depending on the patient's healing mechanism 2) Post Treatment Itching and discoloration of light blue hue under skin associated w/hyaluronic acids Post treatment infection associated with any transcutaneous injection Reactivation of Herpes (cold sores) visible yellow or white patches associated with Radiesse , Granuloma formation Localized Necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs. Failure to achieve desired result. Allergic Reactions, Keloid formation/ hypertrophic scarring (dermal filler treatments are not indicated in individuals who are susceptible to hyper keloid formation)
I, the undersigned and hereby authorize having photographs taken of me and that they may be used as an aid in my treatment, in marketing, or study reporting purposes and that any photographs taken will remain the property of the facility. I understand that my identity will be kept strictly confidential. I also understand that these photographs willhelp document the progress of my treatment. I hereby authorize and consent to the above-described photography.
PREGNANCY, ALLERGIES & DISEASE
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 any of the above-mentioned dermal fillers. I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to Lidocaine.
I understand that this procedure is an elective cosmetic procedure, and that payment is my responsibility. No refunds will be given for treatments received
The nature and purpose of this procedure and the complications and side effects have been fully explained to me. Alternative treatments and their risks and benefits have been explained to me and I understand that I have a right to refuse treatment. I agree to adhere to all safety precautions and instructions after the treatment. No guarantee has been given by anyone as to the results that may be obtained by this treatment. I have read this informed consent and certify that I understand its contents in full. I hereby release Haven Aesthetics of Clermont and the professional performing the procedure from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age and am not under the influence of alcohol or drugs. This consent form is freely and voluntarily executed.