Marlene J. Mash, MD & Associates

Marlene J. Mash, MD & Associates

545 West Germantown Pike, Suite 100, Plymouth Meeting, PA 19462; 484-351-8268;

Artefill® Consent

You are being asked to sign a confirmation that we have discussed the nature of your condition, your contemplated operation or medical procedure, the general nature of the proposed treatment/surgery, the request of the proposed treatment/surgery, the prospects for success, the reasonable therapeutic alternatives to the treatment/surgery, and the risks of such alternatives. Dr. Marlene Mash or one of her Staff has discussed with you the common problems or risks. We also want to ensure that you have been given the opportunity to ask whatever questions you may have had, and that your questions have been satisfactorily answered.

Artefill has proven to be a safe and effective dermal filler for wrinkle correction and was approved by the U.S. FDA in October 2006. In clinical testing, Artefill was as safe as the control temporary dermal filler.

Some people should NOT receive Artefill, including, but not limited to those who:

• had a positive reaction to the Artefill skin test
• have a history of severe allergies, hypersensitivity, or anaphylaxis
• are allergic to the anesthetic (lidocaine) in Artefill
• have a history of allergies to any bovine collagen product
• are prone to thick scar formation (hypertrophic scars) formation and/or excessive scar formations (keloid scars)
• are undergoing or planning to undergo desensitization injections to meat products

Before treatment, you should inform your doctor if you:

• have had any dermal filler treatments in the last 6 months
• are receiving UV light therapy
• are currently on immunosuppressive therapy (medication prescribed for those who have undergone an organ transplant), or are suffering from rheumatoid arthritis, psoriasis, inflammatory bowel disease, cancer, or other conditions.

Alternatives: Alternative methods have been explained to me, as have the advantages and disadvantages. Alternatives to this procedure and the associated risk are to nothave the injection of Artefill.

Risks and Side Effects: Occasionally, there is mild bruising that typically disappears in three to seven days. Less common side effects include rash and itching more than 48 hours after treatment, persistent swelling or redness, and increased sensitivity at some or all injection sites. Two other rare potential side effects of all dermal fillers are lumps and granulomas, both of which can be treated by your physician.Be sure to call our office immediately if you notice any unusual skin reactions around the treatment area.

Consent:

I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated, and that there can be no guarantee as expressed or implied, either as to the success or other result of treatment/surgery or as to cure.This procedure has been explained to me. I hereby state that I have read (or it has been read to me) and I understand this consent, and I understand the information contained in it. I have had the opportunity to ask any questions about the treatment, including risks or alternatives and acknowledge that all my questions about the procedure have been answered in a satisfactory manner. I hereby authorize and direct Dr. Marlene Mash & Associates to perform the following surgical, diagnostic, or medical procedure: Injection of Artefill (methyl methacrylate, micro spheres in gel carrier.

I consent to be photographed before, during and after the treatment. These photographs shall be the property of the Dr. Marlene J. Mash & Associates. These photographs may be published in scientific journals, shown for scientific reasons, and/or used in patient education both in and out of the office; however, my name will not be used. I agree to keep Dr. Marlene J. Mash & Associates informed of any change of address, so that they can notify me of any late findings.

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Patient SignatureDate

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Patient’s Name Printed

Rev 021511