Dermal Filler Informed Consent
DERMAL FILLER CONSENT FORM YOUR DECISION: Dermal Fillers (Hyaluronic Acid) This form is not just a formality- it's a record of your decision to concent to a procedure having considered the risk of both positive and negative outcomes and medical risks listed below, and the impact they may have on your well-being.
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An anesthesia, numbing medicine used to reduce the discomfort of the injection, may or may not be used. The treatment site(s) is washed first with an antiseptic (cleansing) solution. Dermal fillers are to be injected under your skin into the tissue of your face using a thin gauge needle.
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PROCEDURE Dermal fillers are a gel-like dermal implant made of hyaluronic acid (a substance naturally occurring in the human body that can absorb up to 1000x it's weight in water). Facial rejuvenation can be carried out with minimal complications. These dermal fillers are injected under the skin with a very fine needle.
Informed Consent Form for Dermal Filler Free Download
This Dermal Filler Consent Form collects the proper information from the clients that would like to undergo a dermal filler procedure consisting of precautionary information with collecting medical history and signature for the consent.
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The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure named above. It is important that you fully understand this information, so please read this document thoroughly.
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INSTRUCTIONS: This is an informed consent document that has been prepared to help inform you about dermal fillers. It is important that you read this information along with the associated documents provided by Allergan, the provider of the l fillers indicated in this informed consent. The patient info provided by Allergan can be found at
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This consent covers injection using the following dermal fillers: JUVÉDERM® collection of fillers adds volume to a different area of the face to lift cheeks, smooth parentheses lines, or plump the lips. The results are subtle and long-lasting. Each product in the JUVÉDERM® collection of fillers is made from a modified form of Hyaluronic.
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Dermal fillers are clear transparent gels that is injected under your skin into the tissue of your face using a thin gauge needle. 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 site, depth of the wrinkle, and technique used.
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Your consent and authorization for this procedure is strictly voluntary. By signing this consent form, you herby grant authority to Skin Dermatology to perform facial augmentation and/or filler therapy injections using the dermal filler of your choice for any related treatment as may be deemed medically necessary or advisable in the treatment.
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Dermal fillers have been shown to be safe and efective when compared to collagen skin implants and related products to fill in wrinkles, lines and folds in the skin on the face. Its efect can last up to 6 months. Most patients are pleased with the results of dermal fillers use.
Dermal Filler Dissolving Treatment Consent PDF Template
When should I notify my physician? Be sure to report any redness and/or swelling that lasts for more than a few days or any other symptoms that cause you concern to your physician. I have requested the AAAM to attempt to improve my facial lines with Dermal Fillers.
FREE 7+ Sample Dermal Filler Consent Forms in PDF MS Word
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FREE 7+ Sample Dermal Filler Consent Forms in PDF MS Word
DERMAL FILLERS: Restylane -L, Restylane Silk, Restylane LYFT, Restylane Defyne, Restylane Refyne, Perlane-L, Radiesse, Juvederm Ultra XC, Juvederm Ultra Plus XC, Juvederm Voluma XC, Juvederm Volbella XC, Juvederm Vollure XC, Belotero, *Indications.