DERMAL FILLERS PATIENT CONSENT FORM We require all patients to fill out a Dermal Fillers consent form, before proceeding with your scheduled appointment.PLEASE FILL OUT YOUR DERMAL FILLERS CONSENT FORM HERE. Get your form here Dermal Fillers Consent Form Date * MM DD YYYY Name * First Name Last Name INFORMATION * Before the procedure, please read this document carefully. Don’t hesitate to ask questions, Jodie Weir RN is trained in the injection techniques which is overseen by Dr. Ferguson Medical Director, they will be available to answer your questions. Take the time you need before your decision is made. I understand TEOSYAL/ JUVEDERM PRODUCTS AND INDICATIONS (HYALURONIC ACID FILLERS) * These Hyaluronic Acids includes reticulated and non-reticulated gels, as well as gels with or without anesthetic (lidocaine). These products are viscoelastic gels of cross-linked hyaluronic acid except for the (Redensity 1), they are sterile, of non-animal origin, to be injected into the dermis. They are designed for filling wrinkles and lines, correcting the facial oval and/or increasing lip volume. These products provide results within the range of a 6-18-month duration. This means duration depends on several factors: the patients skin type, how fast a patient metabolizes the product, the severity of the wrinkle to be corrected, the injection zone, injection technique and the volume injected. The longevity in the lips may be reduced because of the high vascularization of the lips. TEOSYAL REDENSITY 1 and JUVEDERM VOLITE (SKIN BOOSTERS) non-cross-linked hyaluronic acid gels are designed to improve skin hydration and radiance. Your injector will help you to choose the product for injection according to your aesthetic requirement and goals. A topical anesthetic will be applied to the area of injection as necessary by the injector such as lidocaine to reduce the pain of the injection. A touch up procedure a few weeks after the first injection may help increase persistence and optimize results. Additional costs may apply. I understand PRECAUTIONS FOR USE AND CONTRAINDICATIONS * • Pregnant or breastfeeding women • History of hypersensitivity to one of the components of the products tested (HA lidocaine, vitamins) • History of autoimmune disease or disease affecting the immune system (diabetes, polyarthritis, Rheumatoid arthritis, ankylosing spondylitis, psoriasis, thyroid disorder, scleroderma, inflammatory intestinal disease, lupus, multiple sclerosis, ulcerative colitis, crohn's disease) • Pathology (herpes, acne, rosacea) or unhealed skin alterations • Complications after a surgery during the past 5 years • Previous infections of permanent products (silicone, acrylic polymers, dextran) • Untreated infectious periodontitis, cellulitis of skin or dental or ENT origin, dental abscess untreated or treated less than one week ago • Asymmetry, overcorrection, or under correction I understand SIDE EFFECTS * The TEOSYAL & JUVEDERM products range has been available commercially with the European Union for many years, with several million syringes injected, and on the basis of current data, there is no reason to suspect and unknown risks. However, side effects may potentially occur. Although Hyaluronic acid is a natural constituent of the dermis, an injection of HA is likely to cause a skin reaction as if this molecule was a foreign body. These reactions are usually temporary but influenced, on the one hand, by many external factors (type of producttechnique, site, number of injections and quantity of product injected), and on the other by factors specific to the patient being injected (injection tolerance, photo type, nervousness a at the time of injection, medical history) • Dissatisfaction with the expected aesthetic result • Redness, bruising, ecchymosis, hematomas, edema, itching, mild pain at the injection point which may occur after the injection and is resorbed after 24 hours to 8 days (on average within 72 hours) • Indurations or nodules which may occur at the injection point 15 days to 3 months after the injection • Rare reversible coloring of the injection zone • A remote and rare risk that of filler injection into a blood vessel (blood vessel occlusion) or overfilling tissue that bac block blood flow to the treated area or to the distant areas, causing tissue damage and possible tissue death(necrosis) which can be seen as tissue breakdown or ulceration. • Rare cases of scarring • Increase of bruising or bleeding at injection site if using a substance such as aspirin or ibuprofen or any other blood thinning agents. I have also been informed that in rare cases medical device vigilance have been described in literature. Necrosis to tissue, abscesses, granulomas and hypersensitivity following injections of hyaluronic acid. If you notice any side effects after injection you must contact your injector as soon as possible. I understand Agree to receive TEOSYAL/JUVEDERM range products through the injection procedures. The objectives and methods of the injection procedures have been clearly explained to me by the practitioner/nurse injector. I have received, read and understand the information sheet supplied by the practitioner/nurse injector prior to the injection. I had the opportunity to as any necessary questions. I understand the pre and post-injection recommendations and I agree to follow them. I acknowledge that I had the time required for consideration and to make my informed decision. I acknowledge that have been clearly informed of the side-effects and the rare cases of medical device vigilance. I freely and voluntarily consent to receiving injections. AUTHORIZATION * I have read the information provided in the record consultation for dermal fillers in its entirety and have discussed the risks and benefits of dermal fillers with the physician and or her representative nurse injector. I understand the information provided. My signature below certifies that I have fully read this consent form and understand the written information provided to me regarding the proposed procedure. I have been adequately informed and the procedure including the potential benefits, risks, and limitations. I have had all the questions and concerns answered to my satisfaction. First Name Last Name We respect your privacy. Thank you!
