Consent for Dermal Filler Injections

PATIENT INFORMATION

Full Name

Civil ID

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I undersigned, hereby consent to and authorize Padra Medical Center to carry out intradermal and/or subdermal injections of the hyaluronic acid products commonly used as a filler substance on my (area)

Area(s) of Concern:

Face

Body

This treatment is intended to correct facial lines, wrinkles, folds, lip enhancement or for shaping

I am undergoing treatment of my own free will, I agree that this procedure is being performed for cosmetic reasons and that no guarantees can be made as to the exact results of the procedure.
I have disclosed any old or recent medical history including allergies such as atopic dermatitis, asthma, hypersensitivity to insects and bites, and medications I am allergic to or currently taking.
I understand that every precaution will be taken to prevent complications and although complications from this procedure are rare. They can and sometimes do occur.

I have disclosed any old or recent medical history including:

ALLERGY, DERMATITS, ANGIOAEDEMA, SENSITIVITY TO ANY DRUGS, RECENT OR OLD SURGICAL PROCEDURES.
HISTORY OF PERMANENT FILLERS.
ANY RECENT INFLAMMATION OR INFECTION IN HEAD & NECK OR OTHER AREAS OF THE BODY.
ANY HISTORY OF DIABETES, LOW IMMUNITY, OR ANY IMMUNE SUPPRESSING DRUGS.
ANY HISTORY OF EPILIPTIC FITS.

POTENTIAL SIDE EFFECTS

I have been informed of the potential complication that may occur within four weeks or more after my treatment such as infections, temporary swelling, discomfort, and erythema at the site of injection. Although uncommon, I was also informed of a small number of patients who experienced localized reactions that are hypersensitive in nature such as allergy, itching, and swelling at the implant site, sometimes affecting the surrounding tissues, redness, tenderness, and rarely acne-like formations have also been reported. These reactions have also been described as mild to moderate and self-limiting, some significant and substantial risks/drawbacks of this procedure include bleeding, hematoma, asymmetry, skin necrosis, allergic reaction, skin fistula, scar, facial thrombosis, and cellulitis of the face. It may very rarely cause unilateral blindness.

I am aware that each treatment will be charged individually and according to the amount of material used. I further understand that doctors will evaluate the need to have more injections on the touch up sessions, and that will be charged of any injection accordingly.

To avoid such side effects after the procedure, I must:

Not do any sports, expose to hot water (Shower/Swimming) or no sunlight for 24 hours
Not take any aspirin or ibuprofen or vitamin E for 24 hours following the injections
Avoid any massage to the injection area for 2 weeks after the procedure
Avoid any cosmetology treatment such as peeling, dermabrasion and laser for two weeks after the procedure
Avoid the usage of all kinds of creams and ointments without doctor’s prescription

Photographs

My doctor may/may not take any photographs before or after the procedure for teaching the other medical viewing purposes.

Yes

MEDICINE

Isotretinoin (Roaccutane) (If “Yes” how long have you been using it?)Isotretinoin (Roaccutane) (If “Yes” how long have you been using it?)

Topical Medication (If “Yes” which medicine?)Topical Medication (If “Yes” which medicine?)

Antibiotics (If “Yes” which medicine?)Antibiotics (If “Yes” which medicine?)

Do you take any special medicine? (If “Yes” which medicine?)Do you take any special medicine? (If “Yes” which medicine?)

I have read this information, it has been explained to me, and I understand it. All my questions were answered, as I was given post-treatment instructions.

By signing this form, I indicate that I have no questions and give my full informed consent to have this procedure carried out on me.

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