DERMAL FILLER CONSENT FORM

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    A Dermal Filler is a hyaluronic acid gel, which is found in all living cells and organisms. It is injected into the skin to correct defects and restore lost volume, augment / plump up / accentuate certain features such as lips and cheeks. The aim of treatment is improvement, not perfection.

    Two types of lines on one’s face:

    1. Dynamic - lines formed only on muscle movement (but not present when face is at rest) - best treated with Botulinum Toxin[Botox]
    2. Static - lines present at rest (in absence of facial movement) - only treatable with dermal fillers

    Different facial sites are best treated using different methods - your cosmetic expert will decide and explain as appropriate. Botox used for softening of dynamic lines (wrinkle reduction), and prevention of development of static lines that will occur with repeated long term movement / creasing of the skin. Fillers can be used in conjunction to give better results, but not alone for the treatment of dynamic lines. Fillers used for static line correction either with or without Botox depending on whether or not the area being treated is influenced by muscle movement.

     

    Procedure:

    1. You will see an instant improvement - however, this result is not the final result, as it will take some time for the redness / swelling and consequential distortion, to resolve, and for the remaining fine lines to disappear over time.
    2. Feel the presence of a “sausage” / lump under the skin - that feeling will never go as long as the filler is in place.
    3. Duration - 3-9 months (average 6 months) - dependant on individual factors

    The key is to understand that what you see straight away is not necessarily the final result. Long term, you may end up with palpable lumps remaining as the human body can lay down pieces of scar tissue in response to the mechanical trauma of the injection. These can remain forever, and it is not preventable. Practitioners cannot predict with certainty, how your body will react to accepting the filler or needle trauma - this can vary between individuals and different courses of treatment.

     

    Post-treatment instructions:

    1. Pain / swelling / redness is a guarantee - use periodic ice and NSAIDs for 2-3 days. The redness and swelling will distort result immediately, however will settle spontaneously.
    2. Itching - take over-the-counter antihistamine medication as appropriate
    3. Irritation and tightness in the area that has been filled

    6 hours - avoid alcohol, animated facial expressions and exercise

    • 3 days - avoid manipulation / touching and pressure on the areae
    • 5 days - avoid exposure to extreme hot / cold, and sunlight

     

    Procedure:

    Short term pain, swelling, bruising, itching, rash, temporary discolouration of skin with spontaneous resolution within a week to 10 days normally.

    Long term complications are uncommon, but have been reported in evidence based clinical trials. Tissue reactions - hypersensitivity, allergy, granulomas, permanent lumps / bumps, abscesses, cysts requiring surgical excision, scarring and discolouration of skin (hyper-pigmentations), migration of filler from initial placement site. Hence the Practitioner provides dermal filler treatment in a titrated manner to avoid this complication arising

     

    Dermal Fillers information summary & Disclaimer:

    I have read the information provided by my practitioner, regarding the procedure I will be undertaking. I understand the information given and any questions or queries I have had have been answered. Any medical terminology used in this consent has been explained to me. I am aware of all the risks that are associated with the procedure I will be undertaking.

    I am aware that these products are hyaluronic acid and are designed to restore volume and fill facial lines for contouring and lip augmentation. I understand that more than one treatment session may be required to obtain maximum effects. The possible side effects have been explained to me: hypersensitivity / allergic reaction, swelling and inflammation, granuloma, erythema/redness, pain, tenderness, bruising, swelling, itching, rash, lumpiness, blanching or discolouration, bleeding, infection, and acne. I am aware of the following contraindications, post allergic reaction or hypersensitivity to the product. It has been explained to me, that the product is not permanent filler and that I will need repeat treatments to maintain the results.

    I understand that the practice of medicine and surgery is not an exact science and therefore that no guarantee can be given as to the results of the treatment referred to in this document. I accept and understand that the goal of this treatment is improvement, not perfection, and that there is no guarantee that the anticipated results will be achieved.

     

    Contraindications and precautions:

    pregnancy, lactation, product sensitivity, bone tendon muscle implants, infection in area, abnormal clotting / relevant medication, allergy/anaphylaxis

     

    Post-operative instructions:

    avoid alcohol, exercise, and animated facial expressions for 6 hours after injection. Avoid touching area for 2-3 days. Avoid exposure to sunlight for 3-5 days.

     

    Consent for Clinical Photography

    I understand the importance of pre-treatment photography for both patient satisfaction, and medico-legal reasons, and hereby give my full consent for pre and post treatment photographs to be taken by the clinician. I am aware that these photos will be data protected and information governed, therefore will not be used without further consent.



    Please select yes / no as appropriate, in disclosing your medical history:



    CLIENT CONSENT

    Despite the potential adverse outcomes, I am happy to proceed, and relieve the practitioner from all levels of medico-legal liability in the event of the aforementioned circumstances arising.

    I have been given, and have clearly understood all the information, and the post-operative instructions related to the administration of the agreed product, as stated above. I understand that breach of these guidelines may lead to an increased incidence of post-operative complications and may lead to undesirable cosmetic results.

    I have fully understood that the use of elective injection of HA dermal filler for cosmetic purposes may produce results that vary between individuals, as well as between courses of treatment within the same individual. I understand that therefore, no guarantee can be given as to the results of the treatment referred to in this document. I accept and understand that the goal of this treatment is improvement, not perfection, and that there is no guarantee that the anticipated results will be achieved. I understand and agree to sign this consent form to act as a disclaimer confirming my awareness that this is an elective cosmetic procedure I am undertaking at my own risk, with the associated potential side effects, complications, and undesirable cosmetic outcomes - highly applicable to the process and outcome of a lip augmentation.



    CLIENT'S SIGNATURE:

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    PRACTITIONER'S SIGNATURE:

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    DERMAL FILLER - POST-TREATMENT INSTRUCTIONS

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    1. FOR 6 HOURS - AVOID ALCOHOL, EXERCISE & ANIMATED FACIAL EXPRESSIONS
    2. FOR 2-3 DAYS - AVOID TOUCHING OR MANIPULATION OF THE AREA (PREVENT IMPLANT DISPLACEMENT, LUMP FORMATION OR GRANULOMA FORMATION)
    3. FOR 3-5 DAYS - AVOID EXPOSURE TO SUNLIGHT OR EXTREME COLD

    Immediately after treatment, there may be slight redness, swelling, tenderness, and an itching sensation in the treated area, along with some tightness in the area. This is a normal result of the injection. The inconvenience is temporary and generally disappears in a few days. If the inconvenience continues or if other reactions occur, please contact your physician.

    The initial swelling after lip treatment may last longer, swelling may last up to a week, and lips can look uneven during this time. This means that the result directly after the treatment should not be seen as the final result.

    Avoid touching the area for 8 hours after treatment. After that, the area may be gently washed with soap and water, and light make-up can be applied.

    Until the initial swelling and redness have resolved, do not expose the treated area to intense heat or extreme cold.

    If you have previously suffered from facial cold sores, there is a risk that the needle punctures could contribute to another eruption of cold sores.

    If you are using aspirin or any similar medication, be aware that these may increase the bruising and bleeding at the injection site.

    Dermal filler products are long lasting, but not permanent. A follow-up treatment may be needed after about 6 to 12 months after the initial treatment. A touch-up treatment within 2-4 weeks after the initial treatment may be necessary to achieve an optimal correction. We will review you at 3 weeks for “fine-tuning appointment”- assess for asymmetry and your satisfaction. If necessary, we will re-inject with small volumes to address any small inaccuracies. We will also take post-operative photos at this review appointment.

    Avoid manipulation of the area, including going to sleep lying flat on your back and not on your side. Will experience a little post-procedural discomfort and bruising - NSAID use for a couple of days after treatment. Patient may experience slight tautness or stiffness in the skin in the area.

    If you have had your chin treated - you may experience some temporary difficulty with lower lip mobility, particularly when they smile, due to the transient effect of the procedure on the function of the lower lip depressor muscles.



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