Filler Consent By All Methods

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Patient Information

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Dermal Filler Informed Consent

Pre/Post Care: Any active infections and or Antibiotics, reschedule apt 3 days after last dosage or provide Dr. Note. Avoid alcoholic drinks at least 24 hours prior to treatment (to help prevent bruising due to the blood thinning effects of alcohol) On the day of treatment, avoid vigorous exercise prior to treatment. Avoid anti-inflammatory and blood thinning medications for 2 weeks prior to treatment. Such medications include aspirin, NSAIDs (Ibuprofen, Naprosyn, Aleve) Vitamin E, Ginko Biloba, St. John’s Wort, Coumadin/warfarin, Pletal, Aggrenox. It is recommended that you speak to your physician before discontinuing these medications prior to doing so however. Schedule your injection at least 2 weeks prior to any special occasion/event in case you bruise.


Bruising at the treatment site may occur.

Temporary. minimal to moderate swelling may be expected related to the area/s treated and the product’s used.

It may be normal to experience some tenderness at the treatment site that can last for a few hours or; at times, a couple of days.

It may be normal to feel “firmness” in your treated area/s for the first few days after treatment. Over time, the area/s will soften and “settle”.

Apply cool compresses to the area/s treated (avoiding pressure).

You may begin wearing make up once you have adequately cooled/iced the area/s, and any pinpoint bleeding from the injection site/s has subsided.

DO NOT RUB OR MASSAGE the treated area/a today. When cleansing }’our face or applying make-up, use gentle, sweeping motions to avoid excessive mobility of the area/s.

AVOID strenuous exercise or activity for the remainder of the treatment day. You may resume other normal activities/routines immediately.

You may take acetaminophen/Tylenol if you experience any mild tenderness or discomfort. Avoid aspirin or ibuprofen products, Vitamin E and fish oil, as they may increase your potential to bruise.

AVOID drinking alcohol for a minimum of 12 hours as this may contribute to bruising.

AVOID extended UV exposure until any redness h!is subsided Apply an SPF 30 or higher sunscreen to the treated area/s.

Wait a minimum of 6 weeks before receiving any laser treatments and 1 wk. before skincare treatments.

The indicated dermal filler has been FDA approved for use in cosmetic treatments for moderate to severe wrinkles around the nose and mouth. I understand this treatment is temporary, and re-injection is necessary after about six months. It has been explained to me that other temporary and more permanent treatments arc available.

The following complications may occur with the dermal filler injection procedure:

  1. Risks: I understand there is a risk of bruising, redness, swelling, pain at the injection site tenderness, itching, allergic reaction, and raised bumps of skin (nodules). These symptoms are usually mild and typically last a few days but can last up to a few months. In rare cases bruising can last several months and even be permanent.
  2. Infection: Post treatment bacterial, viral and/or fungal infectious carl occur which in most cases are easily treatable but in rare cases a permanent scarring in the area can occur.
  3. Effectiveness: Treatments can last anywhere from 4-6 months up to one year.
  4. Treatments: I understand more than one injection may be needed to achieve a satisfactory result.
  5. Allergic Reactions: In rare cases7 there may be an allergic reaction to the injection.
  6. There is a risk of scarring.
  7. I will follow all aftercare instructions as it is crucial I do so for healing.

As dermal fillers are not an exact science, there might be an uneven appearance of the face with some areas more affected by the fillers than others. In most cases this uneven appearance can be corrected by more injections in the same or nearby areas. However, in some cases this uneven appearance can persist for several weeks or months.

This list is not meant to be inclusive of all possible risks associated with dermal fillers as there are both known and unknown side effects associated with any medication or procedure.

These dermal fillers should not be administered to a pregnant or nursing woman.

The number of units injected is an estimate of the amount of dermal finer required to add volume to the skin and give the appearance of a smoother face. I understand there is no guarantee of results of any treatment and the regular charge applies to all subsequent treatments. I have read, irritated, and acknowledge these requirements of my procedure to better assist with treatment adversities that can occur if protocol is rot taken seriously. I know that this is an elective service and my questions regarding services have been answered satisfactorily. I understand this procedure and accept all risks and will notify TNP of any changes that could put my treatment at risk, I hereby release The Natural Place, Dr. Copeland, Dr. Buford & Bridget Hahn and staff from all liabilities associated with the indicated procedure.

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