Dermal Filler is a gel of hyaluronic acid, generated by the Streptococcus species of bacteria.  It is chemically cross linked with BDDE, stabilized and suspended in physiologic buffer at PH=7 at a concentration of 20 mg/ml.

Areas most frequently treated are: nasolabial folds, oral commissures, lips, cheeks and the brow area.

You may experience a slight burning sensation during injections. The procedure takes about 20-30 minutes. Results last approximately six months.

Risks and Complications

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

1) Post treatment discomfort, swelling, redness, and bruising

2) Post treatment bacterial, viral, and/or fungal infection requiring further treatment

3) Allergic reaction

4) Potential that the results are not exactly what I expected

Payment

I understand that this procedure is cosmetic and that payment is my responsibility.

 

 

Voluntary Consent

I hereby voluntarily consent to Dermal Filler treatment for Cosmetic Purposes.

The procedure has been explained to
me. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure