Dermal Filler Consultation and Consent Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Date of Consent
-
Month
-
Day
Year
Date
Did you have a proper Good Faith Exam before having any treatments?
Yes
No
Did you honestly confide any possible medical issues or allergies with your Good Faith Exam practitioner?
Yes
No
Were you Referred by a friend? If so, give them credit! They will receive $20 off their next treatment
Will you make your payment with Cash or a Card? (Cash will get you a 4% discount)
Cash
Card
Medical History
Are you currently taking any medications (oral or topical)? * Please List
Are you currently receiving any medical treatment? * Please List
Do you have any allergies? * Please List
Are you (or is there a possibility you may be) pregnant, or are you breastfeeding? *
Yes
No
Have you been unwell recently? *
Yes
No
Do you have any surgery planned in the next 6 months? *
Yes
No
Do you have any cutaneous (skin) infection or inflammatory problems (e.g. herpes/cold-sores, acne etc.)? *
Yes
No
Are you taking any steroids, aspirin or anticoagulant (i.e. warfarin, apixaban etc.)?
Yes
No
Do you have any history of anaphylactic shock or severe allergic reactions? *
Yes
No
Do you tend to develop hypertrophic scarring? *
Yes
No
Have you previously had any Dermal Filler or Botulinum Toxin? *
Yes
No
If so, When was your last treatment?
Have you previously had any sensitivity to hyaluronic acid based products, any dermal filler, lidocaine or local anesthetics? *
Yes
No
Are you undergoing any dental work or have any dental work/hygienist planned? *
Yes
No
Do you have any metal plates in your face? *
Yes
No
Have you taken any Aspirin, Ibuprofen, Fish Oil, Vitamin E in the last five days? *
Yes
No
Emergency Contact Details
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Dermal Filler Treatment
Dermal fillers are injected under the skin with a very fine needle/canaula. This produces natural appearing volume, shape and contour of the lips, cheeks, chin and jaw and folds which are lifted up and smoothed out. The results can often be seen immediately. If have any questions regarding the procedure, ask trainer prior to signing the consent form.
What would you like the treatment to improve or change about your appearance? *
Possible Risks and Complications
Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free.The possible risks of Dermal Filler include, but are not limited to:Post treatment discomfort, swelling, redness, bruising, and discolorationPost treatment infection associated with any transcutaneous injectionAllergic reactionReactivation of herpes (cold sores)Lumpiness, visible yellow or white patchesGranuloma formationLocalized necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occursVision complications
Do you understand these possible complications & verify that the injector is in no way responsible for possible side affects?
Yes
Do you understand these possible complications & verify that the injector is in no way responsible for possible side affects?
Aftercare Advice
Please read carefully. The goal of aftercare is to encourage optimal treatment results. It can also minimize the risk of bruising and spreading to other areas. Follow the aftercare advice provided for optimal results. Don’t touch your skin. Take a break from makeup for 24 hours and don't touch your face. Applying makeup will rub the skin, potentially dispersing the toxin.Wait 24 hours to exercise. If exercise is part of your daily routine, wait at least 24 hours to work out. Physical activity increases blood flow. This could potentially spread the toxin to unintended areas and reduce its effectiveness at the injection site. It also increases the risk of bruising. Exercise also contracts your muscles, which may decrease the toxin’s effectiveness.Sit up. Sit up for the first 4 hours after getting Dermal Filler. Bending or lying down might spread the toxin and promote bruising.Medication. Some medications might increase your risk of bruising. Be sure to ask your practitioner when it’s safe to start taking them again. Avoid aspirin and ibuprofen for a few days following treatment. Do not restart Retinol or Retin-A for 2 days.Don’t drink alcohol. Alcohol increases the risk of bruising. Wait at least 48 hours after your treatment before consuming alcohol.Don't massage, rub or apply pressure to the treated area.Don’t sleep on the treated areas. Try your best to avoid sleeping on the injected areas. This will minimize the physical pressure and let the Dermal Filler settle into your muscles. Also, avoid sleeping within 4 hours after your procedure.Stay out of the sun. Avoid sun exposure for at least 48 hours. The heat can promote flushing and increase your blood pressure, which may encourage bruising.Avoid heat exposure. It’s also best to avoid other forms of heat exposure, such as: Tanning bed, Hot tubs, Hot showers or baths and Saunas.Apply ice. You can apply a pack of ice for relief. The bruising should go away in about 2 weeks.Apply topical cream. You can apply Arnica cream to any areas with redness, bruising or swelling.Avoid waxing and use of chemical depilatories for 1 week following treatment.Wait before having more Aesthetic treatments. Avoid facials, chemical peels, micro-dermabrasion for 2 weeks following treatment. Radio frequency miconeedling must be avoided for 4 weeks.
I have read and understood the aftercare advice given to me on this form.ConsentI accept that any treatment I am going to receive is at my own risk.I certify that I have read, fully understood, and completed this form to the best of my knowledge.I understand that failure to disclose information requested above may result in adverse side effect(s), unknown because of this to which I accept full liability/responsibility.The treatment(s) and possible side effect(s) have been fully explained to me. I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request.I accept that if I am not satisfied with the treatment I will inform the practitioner immediately.I authorize Dr. Fobi and his associates to perform temporary, semi- permanent, or permanent dermal filler injections on me and understand that this procedure is purely elective. I understand and agree that during the course of the procedure, unforeseen conditions may necessitate additional or different procedures than those explained. I request and authorize Sound Integrated Medical Center to use their professional judgment for my care and consent to the use of any anesthesia that Sound Integrated Medical Center may deem appropriate or necessary. I understand that serious complications are rare, but possible and that this treatment may involve risks and complications have been known to follow these treatments even when performed with the utmost care, judgment and skill. Complications may include bleeding, bruising, pain, swelling, scarring, infection, allergic reactions, altered sensation, injury to the skin or deeper tissues resulting in cosmetic defects, and failure to achieve the desired result. I understand that rare complications such as vascular occlusion or embolus can lead to scarring, nerve and blood vessel damage, and facial skin and/or muscle loss. In rare cases, unusual reactions may occur that cannot be predicted. I understand that some areas of treatment are considered “Off Label”. These have been discussed with me and I consent to treatment. I acknowledge that no guarantees have been made to me regarding results, complications, final outcome, or unfavorable results. I accept the risk in hope of obtaining the desired beneficial result of these treatments. I consent to photographs being taken to evaluate treatment effectiveness, for medical education, training, professional publication, promotional and sales purposes. These photographs may be used and displayed publicly without my permission. I understand that I will not be entitled to any compensation as a result of the use of these images. I certify that I have read and understand this form. Pre- and post-treatment instructions have been discussed with me. This procedure, and its specific benefits and risks, and alternatives have been explained to my satisfaction. I understand the potential risks and complications involved and have decided to proceed after considering the possibility of known and unknown risks. I understand that not adhering to the post-care instructions provided will increase my chances of complications. I have had the opportunity to ask questions and have had all of my questions answered to my satisfaction. I freely consent and authorize the proposed treatments. I understand that payment is required at the time of services. By signing this consent, I certify that I am not pregnant or breast feeding. THIS FORM ALSO APPLIES TO ALL FUTURE TREATMENTS
*
Initial Here
I fully understand the above and consent to receive Dermal Filler.
Media Consent
From time to time we may want to take photos or/and videos before, during and after your treatment. We may want to use these photos / videos for educational and promotional purposes including, but not limited to, staff training materials, newsletters, flyers, website, printed advertisements, digital advertisements, social networking sites and other print or digital communications.I consent to the use of photos and videos as indicated by me on this form.I understand I can revoke this at any time by contacting the clinic directly. I can confirm that I have read, or been made aware of how these photos or / and videos will be stored within the organization.Please use this form to confirm for which purposes we have the right to use photos or/and videos of you.
Do you give us permission to take photos / videos of you pre, during and after treatment? *
Yes
No
Signature
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