Please Complete The Following Consent Form
The purpose of this consent form is to provide written information regarding the risks, benefits and alternatives of treatment with Dermal Fillers. This material serves as a supplement to the discussion you have with your BLOOM HEALTH provider. It’s important that you fully understand this material, so please read this information thoroughly. If you have any questions regarding the procedure, ask your BLOOM HEALTH provider prior to submitting this consent form.
TREATMENT GOALS AND DESCRIPTION OF PROCEDURE
Treatment with Dermal Fillers (i.e., Juvederm, Restylane, Revanesse, Belotero, Radiesse, Sculptra and other similar agents) can smooth out facial folds and wrinkles; add volume to the lips, cheeks, chin, temporal hollow, under eye; and contour facial features that have lost their volume and fullness due to aging, sun exposure, illness, etc. Dermal Fillers are injected under the skin with a very fine needle or cannula. This produces natural appearing volume under wrinkles and folds, which are lifted up and smoothed out. The results are visible immediately. Patients usually tolerate the procedure without any significant difficulty. Depending on the treatment area, we apply numbing cream and/or focal anesthesia to minimize discomfort.
TREATMENT RESULTS
Most patients are pleased with the results of their Dermal Filler treatment. 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. Dermal Fillers last temporarily and additional treatments will be required periodically to maintain the full effect. The duration of treatment is dependent on many factors including but not limited to: the type of Dermal Filler used, age, sex, tissue conditions, your general health and lifestyle conditions, and sun exposure. Results may last up to 6 months, and in some cases may last shorter or longer. Occasionally, if the results are unsatisfactory, an injectable enzyme called hyaluronidase (Hylenex) may be used to dissolve/correct treatment with hyaluronic fillers.
AFTERCARE INSTRUCTIONS
Following your Dermal Filler procedure, we’ll provide you with verbal and/or written aftercare instructions. These include, but may not be limited to the following: 1) Keep the head elevated for 3 hours post-treatment; 2) Avoid vigorous exercise for 24 hours; 3) To reduce pain, you may take Tylenol or oral arnica, and NSAIDS if needed; 4) For swelling and bruising, apply ice or topical arnica; 5) Avoid facial laser treatments, microdermabrasion, chemical peels, or microneedling for at least 10 days; 6) Avoid excessive heat, cold and sun exposure for at least 3 days; 7) If at any time you suspect you’re having an unexpected side effect, adverse reaction or complication, contact us immediately, and obtain help in an appropriate medical setting (i.e. BLOOM HEALTH, your primary care provider, specialist, urgent care, or acute care facility). I will adhere to the aftercare instructions supplied to me during my visit.
POTENTIAL RISKS AND COMPLICATIONS
Before undergoing this procedure, understanding the risks is essential. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization, and/or extended outpatient therapy. I understand that there are certain inherent and potential risks and side effects in any invasive procedure, and in this specific instance such risks include but are not limited to: 1) Post treatment discomfort, swelling, redness, bruising, and discoloration; 2) Post treatment infection associated with transcutaneous injection; 3) Allergic reaction; 4) Reactivation of herpes (cold sores); 5) Lumpiness, visible yellow or white patches; 6) Granuloma formation; 7) Rarely, localized necrosis due to blood vessel occlusion, with possible sloughing, and/or scab formation.
PREGNANCY AND CONTRAINDICATED CONDITIONS
I am not aware that I am pregnant. I am not trying to get pregnant. I am not lactating (nursing). I do not have any major illnesses which would prohibit me from receiving Dermal Fillers. I do not have multiple allergies or high sensitivity to medications, including lidocaine.
ALTERNATIVE THERAPY
I understand that this is an elective procedure with goal of improved aesthetic appearance and that the main alternative to therapy is to observe and not receive any treatment. Other available therapies might include sun protection, moisturizers, microneedling, skin resurfacing, or surgery.
PAYMENT
I understand that this service is not covered by insurance, and 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 the procedure at any time.
RELEASE OF LIABILITY
I hereby indemnify BLOOM HEALTH, PLLC from any liability relating to the procedures that I have volunteered for. I understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-treatment questions or concerns to the treating clinician. Furthermore, I hereby indemnify the facility/meeting room/hotel where this treatment is being performed from any liability relating to the procedures that I have volunteered for.
CONSENT TO TREATMENT
By entering my initials below, I hereby voluntarily consent to treatment with Dermal Fillers for facial rejuvenation, wrinkle-smoothing, lip enhancement, replacing facial volume or for other cosmetic purposes, as discussed with and performed by my BLOOM HEALTH provider. I have read the above and understand it. I state that I read and write in English. I am not under the influence of drugs or alcohol. The treatment has been fully explained to me and my questions have been answered satisfactorily. I accept the risks and complications of this elective procedure and I understand that no guarantees are implied as to the outcome of the procedure. Please note this consent is valid for all future Dermal Filler treatments I choose to receive from BLOOM HEALTH.
