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DERMAL FILLER CONSENT FORM YOUR DECISION: Dermal Fillers (Hyaluronic Acid) This form is not just a formality- it's a record of your decision to consent to a procedure having considered the risk of both positive and negative outcomes and medical risks listed below, and the impact they may have on your well-being. INSTRUCTIONS: This is an informed consent document that has been prepared to help inform you about dermal fillers. It is important that you read this information along with the associated documents provided by Allergan, the provider of the l fillers indicated in this informed consent. The patient info provided by Allergan can be found at PROCEDURE Dermal fillers are a gel-like dermal implant made of hyaluronic acid (a substance naturally occurring in the human body that can absorb up to 1000x it's weight in water). Facial rejuvenation can be carried out with minimal complications. These dermal fillers are injected under the skin with a very fine needle. An anesthesia, numbing medicine used to reduce the discomfort of the injection, may or may not be used. The treatment site(s) is washed first with an antiseptic (cleansing) solution. Dermal fillers are to be injected under your skin into the tissue of your face using a thin gauge needle.
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PK !1ó# . ß [Content_Types].xml ¢ ( Ä—]oÓ0 †ï'ø 'oQânH ¡¦»ØÆ%L¢ n]û¤±ðGd»Ûúïq'Öt4ÔÞÒ°›J©í÷}||'s¿z""» c¹V%º(f( E5ãj]¢ïËÏùG"YG #B+(Ñ ,ºZ¼}3_n °™_l‰jçšO [Zƒ$¶Ð (?Ri#‰ó f B '5àËÙì ¦Z9P.w ZÌo " á²ÛGÿwOb@X"]÷ [¯ '¦ œ çIñ½b ¹ä;‡Â¯ìæØš7ö Ç@xС ù·ÁnÝW à dwĸ/Dz ü ÃLÓ ô{(NË. Dermal fillers have been shown to be safe and efective when compared to collagen skin implants and related products to fill in wrinkles, lines and folds in the skin on the face. Its efect can last up to 6 months. Most patients are pleased with the results of dermal fillers use. Dermal fillers are clear transparent gels that is injected under your skin into the tissue of your face using a thin gauge needle. The depth of the injection(s) will depend on the depth of the wrinkle(s) and its location(s) Multiple injections might be made depending on the site, depth of the wrinkle, and technique used. Your consent and authorization for this procedure is strictly voluntary. By signing this consent form, you herby grant authority to Skin Dermatology to perform facial augmentation and/or filler therapy injections using the dermal filler of your choice for any related treatment as may be deemed medically necessary or advisable in the treatment.
FREE 7+ Sample Dermal Filler Consent Forms in PDF MS Word
DERMAL FILLER CONSENT FORM YOUR DECISION: Dermal Fillers (Hyaluronic Acid) This form is not just a formality- it's a record of your decision to concent to a procedure having considered the risk of both positive and negative outcomes and medical risks listed below, and the impact they may have on your well-being. When should I notify my physician? Be sure to report any redness and/or swelling that lasts for more than a few days or any other symptoms that cause you concern to your physician. I have requested the AAAM to attempt to improve my facial lines with Dermal Fillers.
DERMAL FILLERS: Restylane -L, Restylane Silk, Restylane LYFT, Restylane Defyne, Restylane Refyne, Perlane-L, Radiesse, Juvederm Ultra XC, Juvederm Ultra Plus XC, Juvederm Voluma XC, Juvederm Volbella XC, Juvederm Vollure XC, Belotero, *Indications. In fact for many patients, the benefits of treatment with RADIESSE dermal filler last up to a year or more. it is FDA-approved for the correction of moderate to severe facial wrinkles and folds, and for the correction of the signs of facial lipoatrophy in HIV patients. _____ Other Filler _____________________
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Dermal Filler Consent Form Treatment with Hyaluronic Acid Dermal Fillers can help smooth out folds and wrinkles, add volume to the cheeks, temple, lips, and contour facial features that have lost their fullness due to aging, sun exposure, illness, etc. This Dermal Filler Consent Form collects the proper information from the clients that would like to undergo a dermal filler procedure consisting of precautionary information with collecting medical history and signature for the consent.
