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.
- 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,
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.
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.
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