Fillable Printable Informed Consent Form for Dermal Filler

Informed Consent Form for Dermal Filler

Dermal Filler Consent Form

Name: __________________________________________________________________

Telephone: ______________________________________________________________

Email Address: ___________________________________________________________

Address: ________________________________________________________________

Medications: _____________________________________________________________

Allergies: Women: Are you Pregnant or Lactating? ______________________________

Circle any of the following history you have or have had in the past:

History of Anaphylaxis Multiple Severe Allergies Facial Acne

Active Inflammatory process Infection (at proposed injection site) Hives

Immunosuppressive Therapy Autoimmune Disease Herpes

Facial Rashes Any Other Medical Disease: ______________________

EXPLAIN:

Previous Hospitalizations/Operations:

I understand the information on this form is essential to determine my medical and cosmetic

needs and the provision of treatment. I understand that if any changes occur in my medical

history/health I will report it to the office as soon as possible. I have read and understand the

above medical questionnaire. I acknowledge that all answers have been recorded truthfully and

will not hold any staff member responsible for any errors or omissions that I have made in the

completion of the form.

Patient Signature: _____________________________________ Date: ______________

DERMAL FILLER ADMINISTRATION CONSENT

Dermal Filler is a gel of hyaluronic acid generated by streptococcus species of bacteria,

chemically cross linked with BDDE, stabilized and suspended in physiolo gic buffer at PH=7 and

concentration of 20 mg/ml. Areas most frequently treated are: nasolabial folds, oral

commissures, lips, and Glabellar. Client 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 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, and bruising,

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

3) Allergic reaction

PHOTOGRAPHS

I authorize the taking of clinical photographs ant their use for scientific purposes both in

publications and presentation. I understand my identity will be protected.

PREGNANCY, ALLERGIES

I am not aware that I am pregnant, have any significant Medical diseases, or have any severe

allergies.

PAYMENT

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

I hereby voluntarily consent to treatment with Dermal Filler injection for the condition known as:

Facial Static Wrinkles. 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.

Patient Signature: ____________________________________ Date: _______________

Witness Signature: ___________________________________ Date: _______________

Dental Infiltrate Consent

I, _______________________________ understand that a Dental Infiltrate will be performed to provide

temporary relief of discomfort associated with the administration of dermal filler. I understand that Dental

Infiltrates are not 100% effective, but should reduce pain in most cases.

The risks of a Dental Infiltrate include bleeding, infection, and adverse reaction to the anesthetic.

_________ (Initial) I do not have any hypersensitivity to any local anesthetic agents, nor do I have a history of

malignant hyperthermia.

I have read and understand this consent and all of my questions have been addressed and answered to my

satisfaction. I have no contraindicating factors, and thereby grant permission for a Dental Infiltrate. I certify

that if any changes occur in my medical history/health or regime, that I will notify this office as soon as

possible.

________________________________________________________________________________________

Client (Print Name) Signature Date

________________________________________________________________________________________

Witness (Print Name) Signature Date