Client Informed Consent Form

When will I see results and how long will they last?

The results of injections with hyaluronic acid dermal filler are not permanent, meaning that the results will last for a limited period of time. The duration of improvement can range from 2 to 3 months or even up to 1 to 2 years depending upon the filler substance and location of injection, as well as the patient’s reaction to the injection.

What are the possible side effects of hyaluronic acid fillers?

The possible complications of hyaluronic acid filler injection include bruising, swelling, pinpoint bleeding, and other inflammatory symptoms that generally can last a few days (fewer than seven days), as well as unevenness of the skin and unevenness of the filler, which may last for weeks or months. Hypersensitivity as an inflammatory reaction may occur and manifest as swelling, redness, tenderness, induration, and, rarely, acneiform papules at the injection site. There is also a possible incidence of infection, which could cause long-term chronic abscess formations. Localized superficial necrosis may occur after injection in the glabellar area which is thought to result from the injury, obstruction, or compromise of blood vessels.

Furthermore, there is a possibility of numbness, irritation, and tenderness, which may last for a significant period of time in the area of injection. The rare and unusual reactions and risks associated with the use of filler substances include skin infection and inflammatory and granulomatous nodules.

Do not use hyaluronic acid fillers if you have had a history of any of the following conditions:

• recurrent facial herpes simplex without taking an antiviral

• allergy to Xylocaine a local anesthetic

• pregnancy (this treatment is not approved in pregnant women)

• severe allergies manifested by a history of anaphylaxis, or history or presence of multiple severe allergies

I hereby consent to have hyaluronic acid injectable dermal fillers used for the treatment of wrinkles, depressed scars, skin atrophy, and/or volume replacement.

I understand that:

The use of injectable fillers is considered a cosmetic procedure and an elective procedure.Multiple treatment options are available for the treatment of lines, wrinkles, skin laxity and atrophy and these include surgery, the use of lasers (both ablative and non-ablative), the use of radio frequency, and other non-ablative devices with or without the use of neuromodulator agents.

My practitioner will examine me and, depending upon my needs, will suggest the use of specific filler or combination of fillers. Satisfactory correction of my wrinkles or deficits in volume may not be achieved and that whatever correction I have is not permanent and will diminish over time and require additional treatment. My practitioner has made no representations as to the final outcome of the procedure and cannot guarantee my satisfaction with the procedure. 

I understand the above and have had the risks, benefits, and alternatives explained to me. No guarantees or assurances have been made to me concerning the results of such procedures.

I give my informed consent for hyaluronic acid dermal injections today.