Prior to receiving treatments, I have been candid in revealing any condition or information that may have a bearing on this procedure, including but not limited to medical history, medications, pregnancy, breastfeeding, allergies or any neurological disease such as Myasthenia Gravis or Multiple Sclerosis, etc. I will also inform the practitioner prior to receiving additional treatments of any changes relative to my medical history as stated above or any other change I health status that may have an effect on this procedure.

 

The U.S. Food and Drug Administration (FDA) approved the above in December 2003, for use as an injection to help correct moderate to severe facial wrinkles and folds, including the lines between the nose and mouth of a person.

 

The above fillers are FDA-approved and made of a biodegradable non-animal stabilized hyaluronic acid (NASHA™). Upon being injected beneath the skin's surface, the NASHA™ gel adds natural volume and lift to smooth wrinkles and folds. Hyaluronic acid is a natural substance found in all living organisms and provides volume and fullness to the skin.

 

In contrast to non-stabilized hyaluronic acid, which lasts only days to weeks (at most) NASHA™ is developed using a unique stabilization process that results in its long duration of effect. Additionally, unlike other hyaluronic acid products, NASHA™ is not derived from animal sources. It is produced biotechnologically by natural fermentation in a sterile laboratory environment. This significantly diminishes the risk of transmitting diseases between species or of eliciting allergic reactions in patients who are sensitive to common foods, such as beef, chicken and/or eggs. NASHA™ has been extensively researched for over a decade, and proven safe and effective. The above do not require any allergy or skin test prior to injection.

 

In conjunction with the above information, I state I am currently NOT pregnant, actively trying to become pregnant or breastfeeding. I understand the above may NOT be administered 3 months prior to conception. I am not currently taking blood thinners i.e., Coumadin, Plavix or antibiotics i.e., gentamycin, tobramycin, spectinomycin, neomycin, kanamycin, or amikacin. I agree to alert the medical staff if I have any of these conditions or if I am taking any of these medications.

 

Please Initial The above fillers are used extensively for cosmetic purposes worldwide and are approved in the US by the FDA. Since the procedure is considered cosmetic, it is not covered by insurance. I understand that I am responsible for all costs of treatments and that no refunds will be given for treatments received. I understand there are no guarantees as to the results of this treatment, due to many variables such as age, condition of my skin, sun exposure etc. A patient might possibly need multiple treatments or syringes to see improvement or desired effect.

 

Anesthesia:

In a majority of cases, the discomfort associated with injectable procedures can be adequately addressed by either applying ice/cool compresses during procedures via chilled gel and/or ice packs.

 

Procedure:

1. This product is administered via syringe, or injection, into the areas of the face sought to be filled with dermal filler to eliminate or reduce the wrinkles and folds.

2. An anesthesia, numbing medicine used to reduce the discomfort of the injection, may or may not be used.

3. The treatment site(s) is washed first with an antiseptic (cleansing) solution.

4. Dermal fillers are to be injected under your skin into the tissue of your face using a thin gauge needle.

 

1. The depth of the injections will depend on the depth of the wrinkles and their location.

2. Multiple injections may be made depending on the site, depth of the wrinkle and technique used.

3. Following each injection, the injector should gently massage the correction site to conform to the contour of the surrounding tissues.

4. If the treated area is swollen directly after the injection, ice may be applied on the site for a short period.

5.  After the first treatment, additional treatments may be necessary to achieve the desired level of correction.

6. Periodic touch-up injections help sustain the desired level of correction.

 

Risk / Discomfort:

1. Although a very thin needle is used, common injection related reactions could occur. These could include some initial swelling, pain, itching, discoloration, bruising or tenderness at the injection site. You could experience increased bruising or bleeding at the injection site if you are using substances that reduce blood clotting such as aspirin or non-steroidal anti-inflammatory drugs such as Advil.

2. These reactions generally lessen or disappear within a few days but may last for a week or longer.

3. As with injections, this procedure carries the risk of infection. The syringe is sterile and standard precautions associated with injectable materials have been taken.

4. Some visible lumps may occur temporarily following the injection.

5. Some patients may experience additional swelling or tenderness at the injection site and on rare occasions, pustules may form. These reactions might last for as long as two weeks, and in appropriate cases, may need to be treated with oral corticosteroids or other therapies.

6. Dermal fillers should not be used in patients who have experienced hypersensitivity, those with severe allergies to latex or xylocaine products (including but not limited to: Xylocaine [Lidocaine], Novocain, Benzocaine, Prilocaine, or Tetracaine) and should not be used in areas with active inflammation or infections (e.g., cysts, pimples, rashes, or hives).

7. If you are considering laser treatment, chemical peels or any other procedure based on skin response after dermal fillers, or if you recently had such treatments and the skin has not healed completely, there is a possible risk of an inflammatory reaction at the implant site.

8. Most patients are pleased with the results of dermal fillers. 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 treatments to achieve the results you seek. While the effects of dermal fillers can last longer than other comparable treatments, the procedure is still temporary. Additional treatments will be required periodically, generally within 6 months to one year, involving additional injections for the effect to continue.

9. After treatment, you should minimize exposure of the treated area to excessive sun or UV lamp exposure and extreme cold weather until any initial swelling or redness has gone away.

 

Alternatives:

This is strictly a voluntary cosmetic procedure. No treatment is necessary or required. Other alternative treatments include, but are not limited to Botox, Laser Skin Modalities and Cosmetic Surgery.

 

Consent:

Your consent and authorization for this procedure is strictly voluntary. By signing this consent form, you hereby grant authority to your physician's office/authorized medical spa facility to perform Facial Augmentation and/or Filler Therapy injections using the Dermal Filler of your choice for any related treatment as may be deemed necessary or advisable in the treatment areas you so choose. The nature and purpose of this procedure, with possible alternative methods of treatment as well as complications, have been fully explained to my satisfaction. No guarantee has been given by anyone as to the results that may be obtained by this treatment. I have read this informed consent form and certify that I understand its contents in full. I have had enough time to consider this information from my physician's office/authorized medical spa facility, and I feel that I am sufficiently advised to consent to this procedure. I hereby give my consent to this procedure and have been asked to sign this form after being fully informed of the risks and benefits involved.

 

Possible Risk:

The above fillers should not be used in the presence of infection at the proposed injection site(s) and in individuals with known hypersensitivity to any ingredient in the formulation. Patients with neurological disorders such as ALS, multiple sclerosis, myasthenia gravis, or Lambert-Eaton syndrome may be at increased risk of serious side effects. The most common side effects include temporary edema (swelling), bruising, headache, respiratory infection, flu-like symptoms, temporary eyelid droop (ptosis) and nausea. The effects of ptosis are not permanent and will usually subside in 2- 4 weeks.

 

Photographs:

I give permission for identity withholding photographs to be used by the staff for educational / promotional purposes

 

I certify that I am not Allergic to any medication, vitamins, minerals or any other compounded.

If Allergic, please explain:



 

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