Dermal Filler Consent Form

Dermal Filler Injection Informed Consent

Injection of collagen, hyaluronic acid or other filler materials

INSTRUCTIONS

The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure(s) named below. This material serves as a supplement to the discussion you have with your doctor/healthcare provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form.

DESCRIPTION OF THE PROCEDURE(S)

Treatment with dermal fillers 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 aging, 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 or cannula. This produces natural appearing volume under wrinkles and folds which are lifted up and smoothed out. The results can often be seen immediately. This consent covers injection using the following dermal fillers: JUVÉDERM® collection of fillers adds volume to a different area of the face to lift cheeks, smooth parentheses lines, or plump the lips. The results are subtle and long-lasting. Each product in the JUVÉDERM® collection of fillers is made from a modified form of Hyaluronic acid (HA), a naturally occurring substance that delivers nutrients to the skin, helping the skin retain moisture and softness and adding volume. For adults over the age of 21. JUVÉDERM VOLUMA® XC injectable gel is for deep injection in the cheek area to correct age-related volume loss. JUVÉDERM VOLLURE™ XC injectable gel is for injection into the facial tissue for the correction of moderate to severe facial wrinkles and folds (such as nasolabial folds). JUVÉDERM® XC injectable gel is for injection into the facial tissue for the correction of moderate to severe facial wrinkles and folds (such as nasolabial folds). JUVÉDERM® Ultra XC is for injection into the lips and perioral area for lip augmentation. JUVÉDERM VOLBELLA® XC injectable gel is for injection into the lips for lip augmentation and for correction of perioral lines. Sculptra® Aesthetic is FDA-approved injectable made with biocompatible, biodegradable, synthetic material called poly-L-lactic acid, which is gradually and naturally absorbed by the body and helps to rebuild lost collagen through a series of treatments administered by a trained specialist. Indicated for use in people with healthy immune systems as a single regimen for the correction of shallow to deep nasolabial fold contour deficiencies and other facial wrinkles in which deep dermal grid pattern (cross-hatch) injection technique is appropriate. RADIESSE® and RADIESSE® (+) are dermal fillers that are used for smoothing moderate to severe facial wrinkles and folds, such as nasolabial folds (the creases that extend from the corner of your nose to the corner of your mouth). RADIESSE® is also used for correcting volume loss in the back of the hands. RADIESSE is comprised of Calcium Hydroxylapatite (CaHA) microspheres suspended in an aqueous gel carrier. Once injected, it provides immediate volume and correction but continues to work by stimulating the body to produce its own natural collagen. Over time, the gel is absorbed and the body metabolizes the CaHA microspheres leaving behind only your own natural collagen.

BENEFITS

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, once the optimal location and pattern of cosmetic use is established, can last 6 months or longer without the need for re-administration.

LIMITATIONS AND ALTERNATIVES

Most patients are pleased with the results of dermal fillers use. However, like any cosmetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatment to achieve the results you seek. While the effects of Dermal fillers use can last longer than other comparable treatments, the procedure is still temporary and may be effective for variable lengths of time. Dermal fillers will not stop the process of aging. I have been informed of other alternatives which exist for the treatment of wrinkles such as topical creams, chemical peels, laser treatments, surgery on my facial nerves and muscles, cosmetic surgery, dermal fillers derived from the patient’s own fat tissues, or botulinism toxins that can paralyze muscles that cause some wrinkles. No treatment is necessary or required.

POSSIBLE 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 complications that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization, 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: Post treatment discomfort, swelling, redness, and bruising at the injection site Lumpiness, visible yellow or white patches that tend to smooth out over time Visible needle marks Under correction (not enough effect) or overcorrection (too much effect) Facial asymmetry (one side looks different than the other) Post treatment bacterial, and/or fungal infection requiring further treatment Granuloma formation (painful masses in the skin caused when the immune system attempts to wall off substances it perceives as foreign but is unable to eliminate) Localized skin necrosis (tissue death) in facial structures or damage blood flow to the eye resulting in loss of vision if a rare blood vessel occlusion (blockage of a blood vessel) occurs Reactivation of Herpes (cold sores) Allergic reactions that may include itching, rash, red itchy welts, wheezing, asthma symptoms, or dizziness or feeling faint Tell your doctor if you have any side effect that bothers you or that does not go away. Seek immediate medical help if you are wheezing or have asthma symptoms, or if you become dizzy or faint.

CONTRAINDICATIONS

You should NOT have dermal filler injections if you: have skin that is infected or inflamed (filler injection should be delayed until the inflammatory condition has been managed) have skin that is prone to excessive scarring (keloids) and/or thick scarring (hypertrophic scars). have a known bleeding disorder have a history of severe allergies or anaphylaxis are allergic to collagen or eggs are allergic to animal products are allergic to lidocaine

PAYMENT

Payment is due at the time of treatment. All services rendered are charged directly to the patient and the patient is personally responsible for payment. The cost of dermal filler injections may involve several charges. This can include the professional fee for the injections, follow-up visits to monitor the effectiveness of the treatment, and the cost of the material itself. Should complications develop, any further costs for medical treatment would be the responsibility of the patient.

DISCLAIMER

Informed Consent Forms are used to communicate information about the proposed treatment of a condition along with disclosure of risk and alternative treatment(s). The informed consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances. What the healthcare provider and office staff have discussed with you and has been included in this consent are the material risks both common and uncommon that the doctor feels a reasonable person would want to know, understand and consider in deciding if the proposed treatment of a condition is something they would like to proceed with. However, an Informed Consent should not be considered all-inclusive in defining other methods of care and risk encountered. The staff may provide you with additional or different information that is based on all the facts in your particular case and the state of medical knowledge. Informed-consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve.

CONSENT

By signing below I authorize Michele Lane and/or Trained Provider Team members to perform the following procedure(s): JUVÉDERM VOLUMA® XC (HA) Injections JUVÉDERM VOLLURE™ XC (HA) Injections JUVÉDERM® XC (HA) Injections JUVÉDERM® Ultra XC (HA) Injections JUVÉDERM VOLBELLA® XC (HA) Injections Revaness Versa (HA) Injections Sculptra® Aesthetic (poly-L-lactic acid) Injections RADIESSE® (+) Calcium Hydroxylapatite (CaHA) Injections I understand this is an elective procedure and I hereby voluntarily consent to treatment with dermal filler injections for facial folds and wrinkles, add volume to the lips, and/or contour facial features that have lost their volume. The procedures have been fully explained to me and have had enough time to consider it. My questions have been answered satisfactorily and feel that I am sufficiently advised to consent to this procedure. I also understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-operative questions or concerns to the treating clinician. I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I 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.
You have the option to sign this Agreement electronically or sign a paper copy of this Agreement. By signing electronically using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this Agreement (hereafter referred to as your 'E-Signature') is as valid as if you signed this Agreement in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Michele Lane. You are also confirming that you are authorized to enter into this Agreement in your behalf. You understand that a paper copy of this Agreement can also be obtained by contacting Michele Lane at L3Aestheticsinfo@gmail.com or by calling (405) 5703418.