Dermal Filler & Neurotoxin Consent Form
Sign the consent form
(Please note that any cancelation must be made at least 7 days prior to the course in order to receive a refund. Any cancelations made after that time will not qualify for a refund.)
Dermal Filler Section 1
I understand that I will be injected with dermal filler in the following area(s):
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 often necessary. It has been explained to me that other temporary and more permanent treatments are available.
The following risks and or complications may occur with dermal filler injections:
1. Risks: 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 infections can occur which in most cases are easily treatable, but in rare cases permanent scarring in the area may occur.
3. Effectiveness: Treatments can last anywhere from 4-9 months with Hyaluronic Acid Fillers and sometimes up to one year. Treatments with Radiesse can last from 12 to 18 months and sometimes up to 24 months.
4. Treatments: More than one injection may be needed to achieve a satisfactory result. Often times several syringes are required to obtain optimal and full correction.
5. Allergic Reactions: In rare cases, there may be an allergic reaction to the injection(s).
6. There is risk of scarring.
7. I will follow all aftercare instructions as directed for optimal healing.
8. 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.
9. Damage to tissues or nerves can occur.
Dermal fillers are not an exact science, as such, there could be an uneven appearance of the face with some areas more corrected 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.
I understand that no warranty or guarantee has been made to me as to result or cure. I realize that, as in all medical treatment, complications or delay in recovery may occur which could lead to the need for additional treatment, and could also result in economic loss to me because of my inability to return to activity as soon as anticipated. I understand, acknowledge and consent to the procedure with the knowledge of these risks.
*Dermal fillers should not be administered to pregnant or nursing women.
The number of syringes injected is an estimate of the amount of dermal filler 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 understand and agree that all services rendered are charged directly to me and I am personally responsible for payment. I further agree in the event of non-payment, to bear the cost of collection, and/or court cost and reasonable legal fees, should this be required. By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks. I hereby give consent to perfume this and all subsequent dermal filler treatments with the above understood. I hereby release the doctor, the person injecting the dermal filler and the facility from liability associated with this procedure.
Follow-up: I agree to follow-up in 2-4 weeks after my first treatment if asked to do so by my physician.
Cost and Fees: Payment for this cosmetic procedure is my responsibility. Full payment is expected at the time of service.
Neurotoxin Section 1
Botox®, Dysport™ and Xeomin® work by relaxing the muscles of facial expression which cause lines, horizontal forehead lines and crow’s feet. The goal is to smooth out facial lines and wrinkles to give you a more youthful and pleasant appearance. Botox® and Dysport™ do not reduce facial lines or wrinkles caused by aging, heredity, gravity or sun damage.
Botox®, Dysport™ and Xeomin® are a purified form of the botulinum toxin. It has been used for more than a decade in children and adults to improve muscle spasms of the facial muscles. Although Botox® was approved by the FDA for cosmetic use in 2002, the use of Botox® for wrinkles is not covered by insurance and must be paid for by the patient.
Response is usually seen 2-14 days after injection. Treated facial muscles become relaxed for an average of 3-5 months, at which point the muscle action (and wrinkles) will return. Botox®, Dysport™ and Xeomin® may be used in addition to, or in place of other cosmetic procedures. Repeated treatment will relax the muscles and soften the lines again.
Our treatment philosophy is to use the minimum effective amount of Botox®, Dysport™ and/or Xeomin® to achieve the desired effect. At times, an additional session may be needed to fully complete the treatment. The fee for Botox® and Dysport™ treatment is based upon the actual number of units used.
Risks and Complications:
Botox®, Dysport™ and Xeomin® are very safe and are commonly used in much larger doses in other fields of medicine. No long-term side effects have been described with cosmetic use of Botox®, Dysport™ and Xeomin®. Side effects are always possible, including the potential for unknown side effects.
Neurotoxin Section 2
The following side effects have been reported and can occur:
Temporary eyelid drooping or double vision
Burning and/or pain at injection site
Bruising, swelling, and/or hematoma
Headache and flu-like symptoms
Migration to non-target areas
Twitching, itching and/or numbness at injection site
Facial asymmetry (unevenness)
Discoloration and/or scab/scar formation
Incomplete or no response
Skin, respiratory or other infection
Unknown or unreported side effects
May cause birth defects in pregnant women
Muscle and tissue damage
Known significant risks have been disclosed including the potential for unknown complications. I understand that I am at a higher risk for side effects if I do not follow the aftercare instructions.
Limitations and Alternatives:
Botox®, Dysport™ and Xeomin® therapy do not treat or cure the underlying cause or disease of facial wrinkles. Rather it is designed to treat dynamic facial lines caused by facial muscle activity. Treatment may be effective for variable lengths of time, may not work as well or as long as expected, or may not work at all. Lines at rest may or may not improve with this treatment. No promises or guarantees have been made in response to either positive or negative outcomes.
By registering, paying and attending the AESTRA Institute course, I understand that I may be photographed, filmed or videotaped and you expressly give the AESTRA Institute, its owners, agents and principals the right to take pictures and/or recordings of me and use my likeness, image, photo without compensation, for broadcast, display, and exhibition in any medium for purposes of advertisement and education and to put the finished pictures/recordings to any use without limitation. I further expressly release AESTRA Institute from any or all claims or actions arising out of or resulting from any use of my image. However, the AESTRA Institute shall not be obligated to use my image.
***By consenting to this treatment, I agree, affirm and represent that I am waiving my right to seek any recovery for any damages that occur as a result of receiving this treatment whether such damages are as the result of an inherent risk or latent or unintended risk and including any damages that may occur which are not the result of a known or expected risk. I waive any and all recovery for damages of any kind what so ever.***
I have been informed and I understand that the practitioners who will perform this procedure may or may not be licensed to practice in the state of Florida. I have been informed and understand that Aestra Institute and Denise Merdich have not reviewed or investigated whether the practitioners performing this procedure have appropriate licensure within the state of Florida. Despite knowing that the practitioner(s) performing my procedure may or may not be licensed in Florida, I am voluntarily giving consent for the practitioners who may be licensed in other states to practice medicine, nursing, advanced registered nurse practitioners and physician's assistants to perform the procedure on me.