Dermal Filler Consent Form
Sign the consent form below
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.
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.