Fillable Printable Dermal Filler Informed Consent Form

Dermal Filler Informed Consent Form

DERMAL FILLER INFORMED CONSENT

I, _____________ ____und erstand that I will be injected with

dermal filler, in

the following area(s):

The indicated dermal filler has been FDA approved for use in cosmetic treatments for moderate to severe

wrinkles around the nose and mouth. I understand this treatment is temporary, and re-injection is necessary

after about six months. It has been explained to me that other temporary and more permanent treatments are

available.

The following complications may occur with the dermal filler injection procedure:

1. Risks: I understand there is a risk of bruising, redness, swelling, pain at the injection site,

tenderness, itching, allergic reaction, and raised bumps of skin (nodules). These symptoms are usually

mild and typically last a few days but can last up to a few months. In rare cases bruising can last several

months and even be permanent.

2. Infection: Post treatment bacterial, viral and/or fungal infections can occur which in most cases are

easily treatable but in rare cases a permanent scarring in the area can occur.

3. Effectiveness: Treatments can last anywhere from 4-6 months up to one year.

4. Treatments: I understand more than one injection may be needed to achieve a satisfactory result.

5. Allergic Reactions: In rare cases, there may be an allergic reaction to the injection.

6. There is a risk of scarring.

7. I will follow all aftercare instructions as it is crucial I do so for healing.

As dermal fillers are not an exact science, there might be an uneven appearance of the face with some areas

more affected by the fillers than others. In most cases this uneven appearance can be corrected by more

injections in the same or nearby areas. However in some cases this uneven appearance can persist for several

weeks or months.

Th i s l i s t i s not me a n t to be inclusive of all possible risks associated with dermal fillers as there a re both kn own

and unknown side effects associated with any medication or procedure.

These dermal fillers sh ou l d n o t b e a d min i s t er ed to a p reg n a n t o r nu r s in g wo ma n .

The number of units injected is an estimate of the amount of dermal filler required to add volume to the skin

and give the appearance of a smoother face. I understand there is no guarantee of results of any treatment and

the regular charge applies to all subsequent treatments.

I understand and agree that all services rendered are charged directly to me and I am personally responsible for

payment. I further agree in the event of non-payment, to bear the cost of collection, and/or Court cost and

reasonable legal fees, should this be required. By signing below, I acknowledge that I have read the foregoing

informed consent and agree to the treatment with its associated risks. I hereby give consent to perform this and

all subsequent dermal filler treatments with the above understood. I hereby release the doctor, the person

injecting the dermal filler and the facility from liability associated with this procedure.

Patient Signature_______________________________ ________________Date:_ __________ _