Dermal Filler Consent

Name

First NameLast Name

Date of Birth

Date

Introduction

You have requested to receive dermal filler injections at our medical spa. This consent form outlines important details about the procedure, including the risks, benefits, and alternatives of the procedure named above, and confirms your consent to proceed. Please review the following information carefully, ask any questions you may have, and sign where indicated.

Description of the Procedure

Dermal fillers are used to restore volume, reduce wrinkles, and enhance facial contours. The procedure involves the injection of a gel-like substance (such as hyaluronic acid) into targeted areas of the face. This helps to smooth out lines, add volume, and improve overall facial aesthetics.

Indications for Treatment

The procedure is commonly used for:

-Lip enhancement
-Nasolabial folds (smile lines)
-Marionette lines (lines extending downward from the mouth)

Potential Risks and Side Effects

While dermal filler injections are generally safe, potential risks and side effects include:

-Bruising or swelling at the injection site
-Redness or tenderness
-Temporary lumps or uneven appearance
-Migration of the filler material
-Infection (rare)
-Allergic reactions (rare)
-Vascular/arterial occlusion (rare and treatable)

Contraindications

You should not receive dermal filler injections if you have:

-Active skin infections or inflammation at the injection site
-Known allergies to any components of the filler
-Severe allergies and a history of anaphylaxis
-Certain medical conditions, including autoimmune diseases (disclosed upon consultation)

Alternatives to Treatment

Alternative treatments to dermal filler injections include:

-Neurotoxin injections
-Laser resurfacing
-Chemical peels
-Surgical procedures

Pre-Treatment Instructions

-Avoid blood thinners (e.g., aspirin, ibuprofen) for at least 24 hours before the procedure to minimize bruising.
-Refrain from alcohol consumption for 24 hours prior to treatment.
-Inform your provider of any medications, supplements, or allergies at your consultation.

Post-Treatment Care

-Avoid touching or massaging the treated areas for at least 24 hours.
-Apply ice packs to reduce swelling if needed.
-Refrain from strenuous exercise and exposure to extreme heat for the first 48 hours.
-Follow any additional aftercare instructions provided by your healthcare provider.

Payment Responsibility

I understand that this is an “elective” procedure and that payment is my responsibility and is expected at the time of treatment.

Acknowledgment and Consent

I have read and understood the information provided above regarding dermal filler injections. I have had the opportunity to ask questions and have received satisfactory answers. I understand the risks, benefits, and alternatives to the procedure. I consent to the administration of dermal filler injections as described.

Have you received dermal filler injections in the past?

If you answered "yes" to the question above, please indicate where and when dermal filler injections were received.

I consent to the dermal filler injections procedure.

I acknowledge that I have been informed about the potential risks and benefits of the treatment.

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 prohibhit me from receiving dermal fillers. I certify that I do not have multiple allergies or high sensitivity to medications, including, but not limited to, lidocaine or other local anesthetics.

I agree to follow the pre-treatment and post-treatment instructions provided by my Fab Fusion provider.

I understand that results may vary and that no guarantees of outcome have been made.

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

BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ THE FOREGOING CONSENT IN ITS ENTIRETY AND AGREE TO THE TREATMENT AND ITS ASSOCIATED RISKS. I HEREBY GIVE CONSENT TO PERFORM THIS AND ALL SUBSEQUENT DERMAL FILLER TREATMENTS WITH THE ABOVE UNDERSTOOD UNTIL AND UNLESS I WITHDRAW MY CONSENT. I HEREBY RELEASE FAB FUSION AESTHETICS FROM ALL LIABILITIES ASSOCIATED WITH THIS PROCEDURE.

Signature

Date

Form

Dermal Filler Consent