Dermal Fillers Consent Form

Dermal Fillers Consent Form

The dermal filler product used is a sterile consisting of non-animal cross-linked Hyaluronic Acid for injection into the skin to correct facial lines, wrinkles and folds, for lip enhancement and for shaping facial contours.

The use of and indication for the Dermal Filler products have been explained to me by my practitioner and I have had the opportunity to have all questions answered to my satisfaction. I have been specifically informed of the following: after the injection some common injection-related reactions might occur, such as swelling, redness, pain, itching, discoloration and the tenderness at the implant site. They have generally been described as mild to moderate and typically resolve spontaneously within 1-2 days after injection into the skin and within a week after injection into the lips.

Other types of reactions are rare, but approximately 1 in 2000 treated patients have experienced localized reactions thought to be of a hypersensitivity nature. These have usually consisted of swelling at the implant site, sometimes affecting the surrounding tissues. Redness, tenderness and rarely acne-like formations have also been reported. These reactions have either started a few days after the injection or after a delay of 2-4 weeks.

On very rare occasions (less than 1 in 15,000 treatments) prolonged firmness, abscess formation or grayish discoloration at the implantation site has occurred. These reactions can develop weeks to months following the injections and may persist for several months but normally resolve with time. Even more rarely, the formation of a scab and sloughing (shedding) of tissue at the treatment site has been noted, which could result in a shallow scar.

My practitioner has also informed me that depending on the area treated, skin type and the injection technique the effect of the treatment with dermal fillers can last 3-12+months (lips 3-9+ months), but that in some cases the duration of the effect can be shorter or even longer. Touch-up and follow-up treatment helps sustain the desired degree of correction.

Declaration – I hereby certify that I have been fully informed of the nature and purpose of the procedure, expected outcome and possible complications. I understand that there can be no guarantee or assurance as to the final result that may be obtained. I have been given the opportunity to ask questions and hereby certify that I have read and fully understood the contents of this consent form

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