Microsoft word - consent_restylane.doc

RESTYLANE, HYDRELLE & HYLA FORM INFORMED CONS ENT

I_________________, understand that I will be injected with Restylane, Hydrelle or Hylaform,
hyaluronic acid dermal fillers, in the following area(s):
Restylane/Hylaform/Hydrelle are dermal fillers that have been FDA approved for use in cosmetic treatments for moderate to sever 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 are 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. N 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 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
5. Allergic Reactions: In rare cases, 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.
8. If I choose Hydrelle I understand this dermal filler contains the anesthetic lidocaine. If I have
any allergies to lidocaine I will inform my technician prior to the procedure. 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. Restylane, Hydrelle and Hylaform should not be administered to a pregnant or nursing woman. The number of units injected is an estimate of the amount of Restylane, Hydrelle or Hylaform 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 that 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 perform this and all subsequent dermal filler treatments with the above understood. I hereby release the doctor, the person injecting the filler and the facility from liability associated with this procedure.
Patient Signature:
Date: ______

Source: http://aestheticsmedicaltraining.net/wp-content/uploads/2013/12/consent_restylane_hylaform.pdf