To the CLIENT: You have a right to be informed about your condition and its treatment, so that you may decide whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give, or withhold, your consent for treatment.
I ___________________________understand that I will be injected with Hyaluranic or calcium Injectable Dermal Filler in the facial area. These injections are implanted intradermally through a fine gauge needle into the treated area. Hyaluranic Injectable is composed of Hyaluronic acid gel. Calcium injectable is comprised of calcium hydroxylapatite (CaHA) microspheres.
Hyaluranic and Calcium Injectable dermal fillers have been approved by the FDA for use in cosmetic treatments of fine facial wrinkles and folds. I understand that Hyaluranic Injectable 24HV is used for the contouring and volumizing of facial wrinkles and folds; Hyaluranic Injectable 30HV dermal filler is used for volumizing and correction of deeper folds and wrinkles; and Hyaluranic Injectable 30 is used for subtle correction of facial wrinkles and folds. I further understand it will be my physician or nurses’ decision in regards to which product will be used to treat me. Radiesse dermal filler has been FDA approved for use in cosmetic treatments of moderate to severe facial wrinkles such as nasolabial folds.
I understand that multiple treatments are necessary to achieve desired results. Treatments generally last for up to 4 months for Belotero, 9-12 months for Juvederm and Radiesse, 18-24 months for Voluma XC. Touch up treatments may be necessary to maintain desired results. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. Clinical results will vary per patient. I agree to adhere to all safety precautions and regulations during the treatment. No refunds will be given for treatments received. I understand that Radiesse will not correct the underlying cause of facial fat loss but will improve the appearance in the treated area.
Possible Side Effects can include but are not limited to: Allergic reaction or infection, bleeding, tenderness or pain, redness, bruising, scarring, lumps, bumps or swelling at injection site.
People with a history of cold sores may experience a recurrence after the treatment, although this can be minimized by the use of antiviral medicines. I agree to consult with my physician if I have a history of cold sore or fever blisters prior to this treatment.
I am aware that a topical or local anesthetic may be used by my technician to alleviate pain and discomfort. I will advise my technician if I have any allergies of any sort.
I understand if I have a history of Keloid formation or hypertrophic scarring I must advise my physician and I am aware that I will not be eligible for this treatment.
I have advised my physician or nurse if I have severe allergies, particularly allergies to bacterial proteins. If I have an allergy to bacterial proteins I understand I am not a candidate for this treatment. I have also advised my physician or nurse if I have asthma, hay fever, eczema or a history of multiple allergies as any of these issues may increase my risk of allergic reaction.
Microspheres in Radiesse can be seen in X-Rays & CT Scans. I understand I must inform my doctor and other health professionals that I have received Radiesse injections.
I have read and understand the Pre and Post-Treatment Instructions. I agree to follow these instructions carefully. I understand that compliance with recommended pre- and post- procedure guidelines are crucial for healing, prevention of side effects and complications as listed above.
I have advised my physician or nurse if I am pregnant, trying to get pregnant or if I am nursing.
I understand and agree that all services rendered to me are charged to me directly and that I am personally responsible for payment.
The nature and purpose of the treatment have been explained to me. I have read and understand this agreement. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment.
With this form, I give my full consent for all photographs/footage captured, during and after my treatment by Beauty Redefined to remain the property of the clinic.
I release Beauty Redefined, medical staff, and specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.
Note: All prices are subject to change without prior notice
Client’s Signature: Date:
Witness Signature: ___________________________________________________________
I refuse to have my photograph taken, being fully aware that this will eliminate the opportunity to evaluate the effectiveness of my procedure.
Signature: _____________________________ Date: ________________
Post Treatment Instructions
A few guidelines both pre and post-treatment can make a difference between a good result and a fantastic result.
DO NOT touch, press, rub or manipulate the implanted area(s) for 6 hours after treatment. You can cause irritation, sores, and/or problems, and possible scarring if you do.
AVOID: Aspirin, Motrin, Ginkgo Biloba, Garlic, Flax Oil, Cod Liver Oil, Vitamin A, Vitamin E, or any other essential fatty acids at least 3 days after treatment.
AVOID: Alcohol, caffeine, Niacin supplement, high-sodium foods, high sugar foods, refined carbohydrates (you may eat fruit), spicy foods, and cigarettes 24-48 hours after your treatment.
Avoid vigorous exercise and sun and heat exposure for 3 days after treatment.
Discontinue Retin-A 2 days after treatment. It is best to wear no makeup or lipstick until the next day. Earlier use can cause pustules.
Swelling is a normal reaction after treatment with fillers. Swelling may appear unevenly. Swelling should subside after 2 weeks.
One side may heal faster than the other side.
Bruising can occur during or after treatment. Most bruises subside two weeks after treatment.
You must wait two weeks before any treatment correction to allow the original injection to heal and the implant to take full effect.
**** Please report any redness, blisters, or itching immediately if it occurs after treatment.****
I certify that I have been counseled in post treatment instructions and have been given written instructions as well.
Patient Signature: ___________________________________ Date: _________________
Witness Signature: ____________________________________ Date: ________________