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As a patient, you have requested my administration of a stabilized hyaluronic acid used in the correction of moderate to severe facial wrinkles and fold. All medical and cosmetic procedures carry risks and may cause complications. The purpose of this document is to make you familiar with the procedure and its risks in advance. This way, you can decide whether or not to go forward with the process. 

THE PROCESS

  • This product is administered via a syringe, or a special pen, into the areas of the face. - Anesthesia or a numbing medicine can be used to reduce the discomfort - The treatment site(s) is washed first with an antiseptic (cleansing) solution.
  • Hyaluronic acid is a clear transparent gel that will be injected under your skin into the tissue of your face.
  • The depth of the injection(s) will depend on the depth of the wrinkle(s) and its location(s). - Multiple injections might be made depending on the location or depth of the wrinkle. 
  • Following each injection, the service provider should gently massage the correction site to conform to the contour of the surrounding tissues. 
  • If the treated area is swollen directly after the injection, you can apply ice on the site for a short period. 

After the first treatment, additional treatments of Hyaluronic Acid may be necessary to achieve the desired level of correction. 

Periodic touch-up injections help sustain the desired level of correction. HAF corrects an average of 6-12 months. Some products may last up to 18 months. This effect varies depending on general health, dietary and smoking habits, the type of skin, areas injected, and the amount and type of product injected. The duration may be shorter in clients who have a history of smoking, have sun damage, those who continue to suntan, those who undergo heat modalities as Radiofrequency or Ultrasound. Clients who exercise intensively may also have a shorter duration of effect. 

RISKS & DISCOMFORT 

The service provider has discussed with me, and I clearly understand that during and after the injection, there are some potential side effects. Which include and may not be limited to: 

  • Inflammatory reactions such as redness, edema (swelling) and or erythema,
  • Stinging,
  •  Painpressure. 

These reactions may last up to one week or more, depending on my own natural healing. Delayed hypersensitivity reactions, swelling or nodules may develop at the injection site, even up to 6 months or longer after the procedure Very rare cases of discoloration of the injection site have been reported. 

Persistence of inflammatory reactions for more than one week or the development of any other side effect must be reported to the physician as soon as possible. Increase of bruising or bleeding at the injection site if using a substance such as such Ibuprofen (Advil®), Some visible lumps may occur temporarily following the injection. Some patients may experience additional swelling or tenderness at the injection site, and on rare occasions, pustules might form. Some patients may notice temporary numbness or tingling in the area treated that usually will last less than a month to one year. 

ALTERNATIVES

This is a voluntary cosmetic procedure. No treatment is necessary or required. Other alternative treatments which vary in sensitivity, effect, and duration include: animal-derived collagen filler products, dermal fillers derived from the patient's own fat tissues, synthetic plastic permanent implants, or bacterial toxins that can weaken muscles that cause some wrinkles. 
I understand that the injector will choose the dermal filler based on the area to be injected. The injector will recommend the amount of product required for the best results. Changes in the recommendations may alter the outcome of the treatment. 

CONSENT

My consent and authorization for this procedure are strictly voluntary. By signing this informed consent form, I hereby grant authority to the service provider to perform Filler Therapy/Injections using HAF for the treatment of my condition. The nature and purpose of this procedure, with possible alternative methods of treatment, as well as the complications, have been fully explained to my satisfaction. No guarantee has been given by anyone as to the results that may be obtained by this treatment. have read this informed consent and certify that I understand its contents in full. have had enough time to consider the information and feel that I am sufficiently advised to consent to this procedure. understand that any treatment provided may or may not meet my expectations. understand and agree that there is no compensation or refund. am aware of the risks and complications of this procedure, including, but not limited to, bruising, swelling, asymmetry, and blindness. 

Today's Date: November 30, 2022

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

MEDICAL HISTORY

I have informed the staff of the service provider of my medical history, and I clearly understand that I can't get the treatment if 
I am Pregnant or Breastfeeding?*
No
Yes
I am sensitive to hyaluronic acid*
No
Yes
I have severe allergies I am receiving immunotherapy treatments*
No
Yes
In areas presenting with inflammatory and infectious skin problems.*
No
Yes
I tend to develop hypertrophic scarring.*
No
Yes
I have was injected in the past with any semi-permanent or permanent filler (Bioalcamed or Artefill, Sculptra, Radiesse)*
No
Yes

OTHER CONSIDERATIONS Patients who have autoimmune conditions or are significantly inflammatory have a higher chance of inflammatory reactions. Treatment with HAF must be made on a case by case basis with a full understanding of the risks. As with all injections, this procedure carries the risk of infection. The syringe is sterile, and standard precautions associated with injectable materials have been taken. If you are considering laser treatment, chemical skin peeling or any other procedure based on a skin response after HAF treatment, or the skin has not healed completely from a previous procedure, there is a possible risk of an inflammatory reaction at the implant site. Most patients are pleased with the results of HAF's; however, like any cosmetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatments to achieve the results you seek. While the effects of HAF one use can last longer than other comparable treatments, the procedure is still temporary. Additional treatments will be required periodically, generally within six months to one year, involving additional injections for the effect to continue. After treatment, you should minimize exposure of the treated area to excessive sun or UV lamp, exposure and extreme cold weather. 

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

MEDICAL HISTORY

I have informed the staff of the service provider of my medical history, and I clearly understand that I can't get the treatment if 
I am Pregnant or Breastfeeding?*
No
Yes
I am sensitive to hyaluronic acid*
No
Yes
I have severe allergies I am receiving immunotherapy treatments*
No
Yes
In areas presenting with inflammatory and infectious skin problems.*
No
Yes
I tend to develop hypertrophic scarring.*
No
Yes
I have was injected in the past with any semi-permanent or permanent filler (Bioalcamed or Artefill, Sculptra, Radiesse)*
No
Yes

OTHER CONSIDERATIONS Patients who have autoimmune conditions or are significantly inflammatory have a higher chance of inflammatory reactions. Treatment with HAF must be made on a case by case basis with a full understanding of the risks. As with all injections, this procedure carries the risk of infection. The syringe is sterile, and standard precautions associated with injectable materials have been taken. If you are considering laser treatment, chemical skin peeling or any other procedure based on a skin response after HAF treatment, or the skin has not healed completely from a previous procedure, there is a possible risk of an inflammatory reaction at the implant site. Most patients are pleased with the results of HAF's; however, like any cosmetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatments to achieve the results you seek. While the effects of HAF one use can last longer than other comparable treatments, the procedure is still temporary. Additional treatments will be required periodically, generally within six months to one year, involving additional injections for the effect to continue. After treatment, you should minimize exposure of the treated area to excessive sun or UV lamp, exposure and extreme cold weather. 

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

MEDICAL HISTORY

I have informed the staff of the service provider of my medical history, and I clearly understand that I can't get the treatment if 
I am Pregnant or Breastfeeding?*
No
Yes
I am sensitive to hyaluronic acid*
No
Yes
I have severe allergies I am receiving immunotherapy treatments*
No
Yes
In areas presenting with inflammatory and infectious skin problems.*
No
Yes
I tend to develop hypertrophic scarring.*
No
Yes
I have was injected in the past with any semi-permanent or permanent filler (Bioalcamed or Artefill, Sculptra, Radiesse)*
No
Yes

OTHER CONSIDERATIONS Patients who have autoimmune conditions or are significantly inflammatory have a higher chance of inflammatory reactions. Treatment with HAF must be made on a case by case basis with a full understanding of the risks. As with all injections, this procedure carries the risk of infection. The syringe is sterile, and standard precautions associated with injectable materials have been taken. If you are considering laser treatment, chemical skin peeling or any other procedure based on a skin response after HAF treatment, or the skin has not healed completely from a previous procedure, there is a possible risk of an inflammatory reaction at the implant site. Most patients are pleased with the results of HAF's; however, like any cosmetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatments to achieve the results you seek. While the effects of HAF one use can last longer than other comparable treatments, the procedure is still temporary. Additional treatments will be required periodically, generally within six months to one year, involving additional injections for the effect to continue. After treatment, you should minimize exposure of the treated area to excessive sun or UV lamp, exposure and extreme cold weather. 

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

MEDICAL HISTORY

I have informed the staff of the service provider of my medical history, and I clearly understand that I can't get the treatment if 
I am Pregnant or Breastfeeding?*
No
Yes
I am sensitive to hyaluronic acid*
No
Yes
I have severe allergies I am receiving immunotherapy treatments*
No
Yes
In areas presenting with inflammatory and infectious skin problems.*
No
Yes
I tend to develop hypertrophic scarring.*
No
Yes
I have was injected in the past with any semi-permanent or permanent filler (Bioalcamed or Artefill, Sculptra, Radiesse)*
No
Yes

OTHER CONSIDERATIONS Patients who have autoimmune conditions or are significantly inflammatory have a higher chance of inflammatory reactions. Treatment with HAF must be made on a case by case basis with a full understanding of the risks. As with all injections, this procedure carries the risk of infection. The syringe is sterile, and standard precautions associated with injectable materials have been taken. If you are considering laser treatment, chemical skin peeling or any other procedure based on a skin response after HAF treatment, or the skin has not healed completely from a previous procedure, there is a possible risk of an inflammatory reaction at the implant site. Most patients are pleased with the results of HAF's; however, like any cosmetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatments to achieve the results you seek. While the effects of HAF one use can last longer than other comparable treatments, the procedure is still temporary. Additional treatments will be required periodically, generally within six months to one year, involving additional injections for the effect to continue. After treatment, you should minimize exposure of the treated area to excessive sun or UV lamp, exposure and extreme cold weather. 

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

MEDICAL HISTORY

I have informed the staff of the service provider of my medical history, and I clearly understand that I can't get the treatment if 
I am Pregnant or Breastfeeding?*
No
Yes
I am sensitive to hyaluronic acid*
No
Yes
I have severe allergies I am receiving immunotherapy treatments*
No
Yes
In areas presenting with inflammatory and infectious skin problems.*
No
Yes
I tend to develop hypertrophic scarring.*
No
Yes
I have was injected in the past with any semi-permanent or permanent filler (Bioalcamed or Artefill, Sculptra, Radiesse)*
No
Yes

OTHER CONSIDERATIONS Patients who have autoimmune conditions or are significantly inflammatory have a higher chance of inflammatory reactions. Treatment with HAF must be made on a case by case basis with a full understanding of the risks. As with all injections, this procedure carries the risk of infection. The syringe is sterile, and standard precautions associated with injectable materials have been taken. If you are considering laser treatment, chemical skin peeling or any other procedure based on a skin response after HAF treatment, or the skin has not healed completely from a previous procedure, there is a possible risk of an inflammatory reaction at the implant site. Most patients are pleased with the results of HAF's; however, like any cosmetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatments to achieve the results you seek. While the effects of HAF one use can last longer than other comparable treatments, the procedure is still temporary. Additional treatments will be required periodically, generally within six months to one year, involving additional injections for the effect to continue. After treatment, you should minimize exposure of the treated area to excessive sun or UV lamp, exposure and extreme cold weather. 

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

MEDICAL HISTORY

I have informed the staff of the service provider of my medical history, and I clearly understand that I can't get the treatment if 
I am Pregnant or Breastfeeding?*
No
Yes
I am sensitive to hyaluronic acid*
No
Yes
I have severe allergies I am receiving immunotherapy treatments*
No
Yes
In areas presenting with inflammatory and infectious skin problems.*
No
Yes
I tend to develop hypertrophic scarring.*
No
Yes
I have was injected in the past with any semi-permanent or permanent filler (Bioalcamed or Artefill, Sculptra, Radiesse)*
No
Yes

OTHER CONSIDERATIONS Patients who have autoimmune conditions or are significantly inflammatory have a higher chance of inflammatory reactions. Treatment with HAF must be made on a case by case basis with a full understanding of the risks. As with all injections, this procedure carries the risk of infection. The syringe is sterile, and standard precautions associated with injectable materials have been taken. If you are considering laser treatment, chemical skin peeling or any other procedure based on a skin response after HAF treatment, or the skin has not healed completely from a previous procedure, there is a possible risk of an inflammatory reaction at the implant site. Most patients are pleased with the results of HAF's; however, like any cosmetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatments to achieve the results you seek. While the effects of HAF one use can last longer than other comparable treatments, the procedure is still temporary. Additional treatments will be required periodically, generally within six months to one year, involving additional injections for the effect to continue. After treatment, you should minimize exposure of the treated area to excessive sun or UV lamp, exposure and extreme cold weather. 

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

MEDICAL HISTORY

I have informed the staff of the service provider of my medical history, and I clearly understand that I can't get the treatment if 
I am Pregnant or Breastfeeding?*
No
Yes
I am sensitive to hyaluronic acid*
No
Yes
I have severe allergies I am receiving immunotherapy treatments*
No
Yes
In areas presenting with inflammatory and infectious skin problems.*
No
Yes
I tend to develop hypertrophic scarring.*
No
Yes
I have was injected in the past with any semi-permanent or permanent filler (Bioalcamed or Artefill, Sculptra, Radiesse)*
No
Yes

OTHER CONSIDERATIONS Patients who have autoimmune conditions or are significantly inflammatory have a higher chance of inflammatory reactions. Treatment with HAF must be made on a case by case basis with a full understanding of the risks. As with all injections, this procedure carries the risk of infection. The syringe is sterile, and standard precautions associated with injectable materials have been taken. If you are considering laser treatment, chemical skin peeling or any other procedure based on a skin response after HAF treatment, or the skin has not healed completely from a previous procedure, there is a possible risk of an inflammatory reaction at the implant site. Most patients are pleased with the results of HAF's; however, like any cosmetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatments to achieve the results you seek. While the effects of HAF one use can last longer than other comparable treatments, the procedure is still temporary. Additional treatments will be required periodically, generally within six months to one year, involving additional injections for the effect to continue. After treatment, you should minimize exposure of the treated area to excessive sun or UV lamp, exposure and extreme cold weather. 

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

MEDICAL HISTORY

I have informed the staff of the service provider of my medical history, and I clearly understand that I can't get the treatment if 
I am Pregnant or Breastfeeding?*
No
Yes
I am sensitive to hyaluronic acid*
No
Yes
I have severe allergies I am receiving immunotherapy treatments*
No
Yes
In areas presenting with inflammatory and infectious skin problems.*
No
Yes
I tend to develop hypertrophic scarring.*
No
Yes
I have was injected in the past with any semi-permanent or permanent filler (Bioalcamed or Artefill, Sculptra, Radiesse)*
No
Yes

OTHER CONSIDERATIONS Patients who have autoimmune conditions or are significantly inflammatory have a higher chance of inflammatory reactions. Treatment with HAF must be made on a case by case basis with a full understanding of the risks. As with all injections, this procedure carries the risk of infection. The syringe is sterile, and standard precautions associated with injectable materials have been taken. If you are considering laser treatment, chemical skin peeling or any other procedure based on a skin response after HAF treatment, or the skin has not healed completely from a previous procedure, there is a possible risk of an inflammatory reaction at the implant site. Most patients are pleased with the results of HAF's; however, like any cosmetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatments to achieve the results you seek. While the effects of HAF one use can last longer than other comparable treatments, the procedure is still temporary. Additional treatments will be required periodically, generally within six months to one year, involving additional injections for the effect to continue. After treatment, you should minimize exposure of the treated area to excessive sun or UV lamp, exposure and extreme cold weather. 

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

MEDICAL HISTORY

I have informed the staff of the service provider of my medical history, and I clearly understand that I can't get the treatment if 
I am Pregnant or Breastfeeding?*
No
Yes
I am sensitive to hyaluronic acid*
No
Yes
I have severe allergies I am receiving immunotherapy treatments*
No
Yes
In areas presenting with inflammatory and infectious skin problems.*
No
Yes
I tend to develop hypertrophic scarring.*
No
Yes
I have was injected in the past with any semi-permanent or permanent filler (Bioalcamed or Artefill, Sculptra, Radiesse)*
No
Yes

OTHER CONSIDERATIONS Patients who have autoimmune conditions or are significantly inflammatory have a higher chance of inflammatory reactions. Treatment with HAF must be made on a case by case basis with a full understanding of the risks. As with all injections, this procedure carries the risk of infection. The syringe is sterile, and standard precautions associated with injectable materials have been taken. If you are considering laser treatment, chemical skin peeling or any other procedure based on a skin response after HAF treatment, or the skin has not healed completely from a previous procedure, there is a possible risk of an inflammatory reaction at the implant site. Most patients are pleased with the results of HAF's; however, like any cosmetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatments to achieve the results you seek. While the effects of HAF one use can last longer than other comparable treatments, the procedure is still temporary. Additional treatments will be required periodically, generally within six months to one year, involving additional injections for the effect to continue. After treatment, you should minimize exposure of the treated area to excessive sun or UV lamp, exposure and extreme cold weather. 

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

MEDICAL HISTORY

I have informed the staff of the service provider of my medical history, and I clearly understand that I can't get the treatment if 
I am Pregnant or Breastfeeding?*
No
Yes
I am sensitive to hyaluronic acid*
No
Yes
I have severe allergies I am receiving immunotherapy treatments*
No
Yes
In areas presenting with inflammatory and infectious skin problems.*
No
Yes
I tend to develop hypertrophic scarring.*
No
Yes
I have was injected in the past with any semi-permanent or permanent filler (Bioalcamed or Artefill, Sculptra, Radiesse)*
No
Yes

OTHER CONSIDERATIONS Patients who have autoimmune conditions or are significantly inflammatory have a higher chance of inflammatory reactions. Treatment with HAF must be made on a case by case basis with a full understanding of the risks. As with all injections, this procedure carries the risk of infection. The syringe is sterile, and standard precautions associated with injectable materials have been taken. If you are considering laser treatment, chemical skin peeling or any other procedure based on a skin response after HAF treatment, or the skin has not healed completely from a previous procedure, there is a possible risk of an inflammatory reaction at the implant site. Most patients are pleased with the results of HAF's; however, like any cosmetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatments to achieve the results you seek. While the effects of HAF one use can last longer than other comparable treatments, the procedure is still temporary. Additional treatments will be required periodically, generally within six months to one year, involving additional injections for the effect to continue. After treatment, you should minimize exposure of the treated area to excessive sun or UV lamp, exposure and extreme cold weather. 

Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

MEDICAL HISTORY

I have informed the staff of the service provider of my medical history, and I clearly understand that I can't get the treatment if 
I am Pregnant or Breastfeeding?*
No
Yes
I am sensitive to hyaluronic acid*
No
Yes
I have severe allergies I am receiving immunotherapy treatments*
No
Yes
In areas presenting with inflammatory and infectious skin problems.*
No
Yes
I tend to develop hypertrophic scarring.*
No
Yes
I have was injected in the past with any semi-permanent or permanent filler (Bioalcamed or Artefill, Sculptra, Radiesse)*
No
Yes

OTHER CONSIDERATIONS Patients who have autoimmune conditions or are significantly inflammatory have a higher chance of inflammatory reactions. Treatment with HAF must be made on a case by case basis with a full understanding of the risks. As with all injections, this procedure carries the risk of infection. The syringe is sterile, and standard precautions associated with injectable materials have been taken. If you are considering laser treatment, chemical skin peeling or any other procedure based on a skin response after HAF treatment, or the skin has not healed completely from a previous procedure, there is a possible risk of an inflammatory reaction at the implant site. Most patients are pleased with the results of HAF's; however, like any cosmetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatments to achieve the results you seek. While the effects of HAF one use can last longer than other comparable treatments, the procedure is still temporary. Additional treatments will be required periodically, generally within six months to one year, involving additional injections for the effect to continue. After treatment, you should minimize exposure of the treated area to excessive sun or UV lamp, exposure and extreme cold weather. 

Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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