Dermal Filler Consent Form
Hyaluronic acid fillers are injectables gels that are used to restore volume to skin, improve facial lines, wrinkles and folds as well as to enhance facial contours. This effect will be noticeable immediately after injection with full results seen in 14 days. Fillers are temporary and can last anywhere from 6 to 18 months depending on the type of filler used, the location injected, and the number of syringes used.
By signing my name below, I indicate that:
I understand that the goal of treatment is to help restore skin volume and soften folds and wrinkles.
I understand that it is in my best interest to avoid blood thinners such as alcohol, aspirin products, NSAIDS, high dose garlic, ginseng, gingko or other herbal supplements up to three days before treatment.
I understand in the first few days after injection the filler is movable. I understand that I am not to manipulate the area injected and I should sleep on my back.
I understand that just as there may be benefits from the procedure, all procedures involve some degree of risk. I understand that the following are among the expected side effects of Hyaluronic Acid fillers procedures:
- Discomfort: Most patients will feel some discomfort associated with the treatment. This discomfort is usually temporary during the procedure and localized within the treatment area. There can be some tenderness to the localized area for up to two weeks after the procedure.
- Redness and Swelling: After treatment most patients can expect to have redness or swelling to the areas injected . This common side effects typically lasts 2-3 days post treatment and can last upwards of 2 weeks.
- Bruising: Due to many vessels W1derlying the skins surface, bruising can be a common side effect that can last up to 7-14 and be substantial in size and colour depending on the area injected.
- Smal Nodules: While the filler is settling into the tissue you may be able to feel some non-tender nodules under the surface of the skin. This is usually temporary and can last up to 2 weeks. In some cases, the nodule can last indefinitely.
- Herpes Simplex Reactivation: Herpes Simplex Virus (cold sore) eruption may result in cases where filler is injected in a treated area that has previously been infected with the virus. This is typically true in the case of lip fillers.
I understand that the following are among the possible risks and/or complications, mainly temporary, associated with the Neuromodulator procedure:
- Diplopia: In rare cases the Neuromodulator can diffuse to a muscle responsible for moving your eye from left to right causing you to have temporary double vision that can last up to 3-4 months.
- Asymmetry: All faces are not perfectly symmetrical, and although we strive to create balance, in some cases, H yaluronic acid filler can move from the site of injection when under pressure and this can result in facial asymmetry.
- Keloid Scarring: Although rare, scarring is a possibility due to the disruption to the skin’s surface and/or abnormal healing. Scars, which can be permanent, may be raised or depressed, and scarring could lead to loss of pigment or increased pigment (“hypopigmentation/hyperpigmentation”) in the scarred area.
- Pigment Changes: Although rare, during the healing phase, the treated area may appear to be darker. This is called PIH (“post inflammatory hyperpigmentation”). PIH occurs more frequently with darker colored skin, after sun exposure to the treatment area, or with patients who already have a tan.
- Infection: Every time you are injecting through the skin there is a chance that there is a portal of entry for infection.
- Allergic Reaction: Patients can be allergic to the neuromodulator and have varying allergic responses to it.
- Efficacy: Because all individuals are different, it is not possible to completely predict who will benefit from the procedure and how long the filler will last. Some patients will have very noticeable improvement, while others may not fall within the expected outcomes.
- Arterial/Venous Embolism: An extremely rare adverse event that occurs when the gel is injected into a blood vessel and can result in severe skin breakdown or blindness.
- I understand and am aware that other unexpected risks or complications may occur and that no guarantees or promises have been made to me concerning the results of the procedure.
For the purpose of adequate record keeping, I consent to have this clinic’s staff take before and after treatment photographs of the involved area(s). These photos will be used for medical records and shall be treated with the same confidentiality as the remainder of my records.
I understand that HA Fillers may be applied in areas that are considered “off label” by the manufacturer and Health Canada. My injector may recommend other areas including but not limited to areas in the dermis, subcutaneous tissue, muscle and supraperiosteal space.
I understand that Hyaluronic Acid fillers treatment cannot be performed on patients who are currently pregnant, breastfeeding or have an allergy to one or more Hyaluronic acid fillers. I will notify the Physician or Nurse if I have a have a history of neurological disease (including muscular sclerosis), as well ifl have a predisposition to keloid formation.
I understand that post-operative instructions need to be followed in order to avoid potential complications and unsatisfactory results. These post care instructions include:
- Keeping the skin clean, especially for the first 48 hours, you may apply makeup gently after 6 hours
- The gel is quite moveable for the first several days, keep the area relaxed after treatment and avoiding massage or manipulation of the area. Try to sleep on your back.
- Avoiding strenuous physical exercise, hot tub, saunas, facials, alcohol and or aspirin/ NS AIDS for 24 hours after treatment.
By signing below, I voluntarily consent and authorize Hyaluronic acid fillers treatments to be performed on me by Physicians, Nurse Practitioners, International Medical Graduate and/or Nurses. Further, my signatre indicates that I have read the contents of this form and I understand the information presented. All of my questions have been answered to my complete satisfaction. I am fully aware of the potential risks of Hyaluronic acid fillers treatments and have been adequately informed alternative treatment options. I hereby agree to free the injector, the staff, and Refresh Evolution from any and all claims or suits for damage, for injuries or complications resulting from service provided by the injector including costs of medical care that may arise from the procedure, including post procedure care. I understand that there will be no refunds after treatment of this elective procedure. Any packages paid for in full are non-refundable and has no monetary value that may be transferred to product.