Dermal Filler Consent

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IF YOU HAVE ANY QUESTIONS REGARDING THIS TREATMENT, PLEASE ASK YOUR CLINICIAN PRIOR TO SIGNING THIS CONSENT. Hyaluronic Acid dermal fillers (such as Juvederm, Belotero, Restylane, Profhilo and others) can be injected to smooth out facial folds and wrinkles, add volume to the lips, and contour facial features. Facial rejuvenation can usually be carried out with minimal complications. The goal of the treatment is to provide you with a natural looking refreshed appearance. The results can often be seen immediately however the treatment may take a few weeks to settle and integrate into your tissue.(Required)
I have disclosed my medical and drug history to my clinician and am aware that many medications increase the risk of bruising and include but are not limited to: Fish oil, Vitamin E, aspirin, Motrin, clopidogrel, warfarin and others.(Required)
PREGNANCY, BREASTFEEDING, ALLERGIES & AUTOIMMUNE DISEASE - I am not aware that I am pregnant. I am not trying to get pregnant. I am not breastfeeding. I do not have or have not had any major illnesses which would prohibit me from receiving dermal fillers. I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to lidocaine. I have also disclosed any autoimmune conditions that I have or am being investigated for.(Required)
If you are having lower face or lip injections and suffer from cold sores, it is advised you start prophylactic treatment on the day of or prior to your injections.(Required)
RISKS AND COMPLICATIONS - Potential risks and side effects of this treatment include but are not limited to: 1) Post treatment discomfort, swelling, redness, bruising (common); 2) Infection or allergy (immediate or delayed) ; 3) Reactivation of herpes (cold sores); 4) Lumpiness or granulation formation; 5) Vascular occlusion (very rare) which may result in tissue necrosis, blindness or stroke.(Required)
FOLLOWING YOUR TREATMENT avoid exercise and make up until the next day. You may ice through a clean face cloth, 20 minutes on and 20 minutes off if you experience bruising/swelling. Applying hirudoid or arnica cream may help speed recovery. Avoid touching/playing with the treated area. Ensure you have clean pillow slips. Ideally you will sleep on your back with an additional pillow to assist lymphatic drainage. Most swelling should settle within 72 hours. If your swelling is excessive an over the counter anti-histamine (hayfever tablet) may be beneficial. Some injection sites may be achy, if this is the case you may take paracetamol but should avoid anti-inflammatory medication (eg neurofen) today as it could exacerbate bruising. PLEASE NOTE LIPS AND TEAR TROUGHS are particularly prone to swelling post injection, so please schedule your treatment at a time that allows for this.(Required)
FOR THE NEXT 3 DAYS, if you notice any irregular skin colour such as blanching of the skin, or a grey area (that doesn’t look like a small bruise), any unusual patterns on your skin, pimples, pustules, excessive swelling OR ANYTHING ELSE OF CONCERN. Please notify your Kate Allen, immediately.(Required)
FOR 4 WEEKS FOLLOWING TREATMENT -avoid any sustained pressure of the treated area (eg swimming goggles, face down massages, facial treatments etc). During this period some clients can still feel the filler – this is normal and will soften, please avoid playing with it or excessive massage. If you do notice a small lump or bump you can apply gentle pressure to it in the first 2 weeks to help the product to integrate with your own tissue.(Required)
ALTERNATIVE PROCEDURES Alternatives to the procedures and options that I have volunteered for have been fully explained to me. PAYMENT I understand that this is an "elective” procedure and that payment is my responsibility and is expected at the time of treatment. RIGHT TO DISCONTINUE TREATMENT I understand that I have the right to discontinue treatment at any time. PHOTOGRAPHY I understand that clinical photographs and/or videos will be taken for record keeping purposes. These will remain confidential and only be shared with yourself and other healthcare professionals involved in your care. Clinical photographs will be not be used for any other purpose without additional consent, eg shown to other clients or used for education or published online or on social media for advertising or marketing purposes. Should your healthcare provider wish to use your photographs for these purposes, you will be notified and additional consent will be obtained.(Required)
RESULTS Most patients are pleased with the results of dermal fillers use. However, like any aesthetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatment to achieve the results you seek - in most cases dermal filler will soften the appearance of wrinkles, not erase them. The dermal filler procedure is temporary and additional treatments will be required periodically, generally within 9- 12 months, involving additional injections for the effect to continue.(Required)
You are encouraged to attend a treatment review 2-3 weeks following your injections – this can be booked online at kateallen.co.nz/book (this is complimentary).(Required)
I hereby voluntarily consent to treatment. The procedure has been fully explained to me.t I will direct all post-operative questions to KATE ALLEN (RN). I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history I will notify the Kate Allen immediately.(Required)

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