Dermal Filler Consultation and Consent Form

PERSONAL INFORMATION

MEDICAL HISTORY

FACIAL HISTORY

FACIAL INJURY TRAUMA HISTORY

I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform the practitioner or other health professional of my current medical health conditions and to update this history. A current medical history is essential for the practitioner to execute appropriate treatment procedures.

FILLER PRETREATMENT INSTRUCTIONS

7 Days Before 

• To avoid bruising it is best not to take any anti-inflammatory medication or pain relievers that are blood thinners such as aspirin, Tylenol, Advil, or Motrin
• Avoid the following vitamins & supplements: Vitamin E, Fish Oil, Omega 3 fatty acids, Ginkgo biloba, Garlic, Ginger, cayenne, liquorice, flax seed oil and COQ10
• Avoid drinking alcohol a few days before treatment since it, too, is a blood thinner
• Sunburned skin is difficult to treat so avoid exposure to the sun before your appointment
• Avoid waxing, bleaching, tweezing, facial scrubs or the use of hair removal cream on the area to be treated
• Avoid the use of Alpha Hydroxy Acids higher than 10%, Retinol and Retinol A
• If you have a tendency to bruise easily, start taking Arnica Montana, an oral homeopathic medication 3-4 days before treatment to help promote healing, minimise bruising and swelling. It comes in an oral tablet and a topical cream. The cream may be helpful after treatment.
• If you have a history of cold sores (Perioral Herpes) the practitioner will prescribe a medication for you to start the day before or the day of treatment.
• Always inform your clinician of all medications including antibiotics, high blood pressure medication, Coumadin, Plavix, or other blood thinners as well as your medical history.
  
  Other Important Information: 
  
  
• Patients should be in good overall health.
• Do not use dermal fillers if you are pregnant/breastfeeding
• Active skin infections are a contraindication to treatment
• Stay well hydrated before and after filler treatment. Dermal filler attracts and binds to water to add volume to the skin.
• Schedule a follow up appointment 2 weeks after treatment. 

INFORMED CONSENT FOR DERMAL FILLER TREATMENT

THE TREATMENT
The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure named above. This material serves a supplement to the discussion you have with your practitioner. It is important that you fully understand this information, so please read this document thoroughly. If have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form. Treatment with dermal fillers (such as Juvederm Ultra and Ultra Plus, Restylane, Belotero, Radiesse, Voluma and others can smooth out facial folds and wrinkles, add volume to the lips, and contour facial features that have lost their volume and fullness due to ageing, sun exposure, illness, etc. Facial rejuvenation can be carried out with minimal complications. These dermal fillers are injected under the skin with a very fine needle. This produces natural appearing volume under wrinkles and folds which are lifted up and smoothed out. The results can often be seen immediately. 

RISKS AND COMPLICATIONS

Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalisation, and/or extended outpatient therapy to permit adequate treatment. 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, bruising, and discolouration; 2) Post treatment infection associated with any transcutaneous injection; 3) Allergic reaction; 4) Reactivation of herpes (cold sores); 5) Lumpiness, visible yellow or white patches; 6) Granuloma formation; 7) Localised necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs.

PREGNANCY, ALLERGIES & NEUROLOGIC DISEASE

I am not aware that I am pregnant and I am not trying to get pregnant, I am not lactating (nursing). I do not have any significant neurologic disease including but not limited to myasthenia gravis, multiple sclerosis, lambert-eaton syndrome, amyotrophic lateral sclerosis (ALS), and parkinson’s. I do not have any allergies to the toxin ingredients, to human albumin or eggs.

ALTERNATIVE PROCEDURES

Alternatives to the procedures and options that I have volunteered for have been fully explained to me.

PAYMENT

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

RIGHT TO DISCONTINUE TREATMENT

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

RESULTS

Dermal fillers have been shown to be safe and effective when compared to collagen skin implants and related products to fill in wrinkles, lines and folds in the skin on the face. Its effect can last up to 6 months. Most patients are pleased with the results of dermal fillers use. However, like any aesthetic procedure, there is no guarantee that you will not require additional treatments to achieve the results you seek. The dermal filler procedure is temporary and additional treatments will be required periodically, generally within 4-6 months and up to one year, involving additional injections for the effect to continue. I am aware that follow-up treatments will be needed to maintain the full effects. I am aware the duration of treatment is dependent on may factors but not limited to: age, sex, tissue conditions, my general health and life style conditions, and sun exposure. The correction, depending on these  factors, may last up to 1 year and in some cases shorter and some longer. I have been instructed in and understand the post-treatment instructions. I understand this is an elective procedure and I hereby voluntarily consent to treatment with dermal fillers for facial rejuvenation, lip enhancement, establish proper lip and smile lines, and replacing facial volume. The procedure has been fully explained to me. I also understand that any treatment performed is between me and the practitioner who is treating me and I will direct all post-operative questions or concerns to the treating clinician. I have read the above and understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history I will notify the doctor/healthcare professional who treated me immediately. I also state that I read and write in English.

I am the treating practitioner, I discussed the above risks, benefits, and alternatives with the patient. The patient had an opportunity to have all questions answered and was offered a copy of this formed consent. The patient has been told to contact my office should they have any questions or concerns after this treatment procedure.

I hereby give my consent for the Practitioner/Technician to take photos or videos before/during and after of any treatments, which maybe used only for promotional purposes on the company's social media & website.

Post Treatment Instructions

• Do not massage, rub or apply pressure to the treated area for 6 hours after treatment


• Avoid aspirin, ibuprofen, and drinking alcohol for a few days following treatment


• Do not exercise for 24 hrs.


• Apply topical Arnica Montana cream to any areas with redness, bruising or swelling


• Avoid exposure to the sun and cold outdoor activities until redness from treatment disappears


• Do not restart Retinol or Retin-A for 2 days
  


• Avoid kissing, puckering, using a straw, and “lip plumpers”. This can displace the filler material and cause complications.


• Immediately apply ice to the area treated with very light pressure to reduce swelling. Ice should be applied for 10-20 minutes and then removed for 10-20 minutes. This cycle can be continued throughout today.


• Mild to moderate bruising is very common with fillers. Apply Topical and/or oral Arnica Montana to help with any areas of bruising and/or swelling.


• Stay well hydrated can improve results. Filler attracts and binds to water to add volume to the skin.


• Avoid facials, peel, micro-dermabrasion, dental treatment, “face down” massages for two weeks. Also, sleep on your back for the next few nights.


• If possible, avoid makeup today. Gentle cleansing and moisturizer is fine.


• The effect of filler is immediate with full effect in 7 days.

Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.

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