This informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure you are about to undertake. This material serves as a supplement to the discussion you have with your doctor/healthcare/medical provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form. Dermal filler treatment with dermal fillers can smooth out facial folds and wrinkles, add volume to the lips, and contour facial features that have lost their volume and fullness due to ageing, sun exposure, illness, etc.
RISKS AND COMPLICATIONS Understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalisation, and/or extended outpatient therapy to permit adequate treatment. It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include but are not limited to: 1) Post treatment discomfort, swelling, redness, bruising, and discolouration; 2) Post treatment infection associated with any transcutaneous injection; 3) Allergic reaction; 4) Reactivation of herpes (cold sores); 5) Lumpiness, visible yellow or white patches; 6) Granuloma formation; 7) Localised necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs.
PUBLICITY MATERIALS I authorise the taking of clinical photographs and videos. I understand that photographs and video may be taken of me for educational and marketing purposes. I hold the practitioner harmless for any liability resulting from this production. I waive my rights to any royalties, fees and to inspect the finished production as well as advertising materials in conjunction with these photographs.
RESULTS Dermal fillers have been shown to be safe and effective when compared to collagen skin implants and related products to fill in wrinkles, lines and folds in the skin on the face. Its effect can last up to 12 months.. However,, there is no guarantee that you will be completely satisfied. There is no guarantee that you will not require additional treatment to achieve the results you seek. The dermal filler procedure is temporary and additional treatments will be required periodically, generally within 4-8 months. I am aware that follow-up treatments will be needed to maintain the full effects. I am aware the duration of treatment is dependent on many factors. I have been instructed in and understand the post-treatment instructions. The results may need a downtime period of up to 2-4 weeks of recovery
RIGHT TO DISCONTINUE TREATMENT I understand that I have the right to discontinue treatment at any time & I understand payment will still have to be made in full.
PAYMENT I understand that this is an ‘elective’ procedure and that payment is my responsibility and is expected at the time of treatment. I understand this is an elective procedure & the procedure has been fully explained to me. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history I will notify the doctor/healthcare professional who treated me immediately. I also state that I read and write in English.
I certify by signing this form that you have read the information in this document and completely understand it. I choose to proceed based entirely on the information provided in this informed consent document. You have been given all necessary opportunities for discussion and all your questions regarding dermal filler