Purpose of This Consent Form
This consent provides written information regarding the risks, benefits, and alternatives of injectable
aesthetic treatments performed at Bloom Health. These treatments may include
botulinum toxin type A neuromodulators,
hyaluronic acid (HA) dermal fillers and similar volumizing gels,
poly-L-lactic acid (PLLA) biostimulatory fillers,
calcium hydroxylapatite (CaHA) biostimulatory fillers,
deoxycholic acid (DCA) fat-dissolving injections, and
autologous regenerative injectables such as PRP, PRF, EZ Gel, PRFM, and similar
platelet-derived or autologous bio-gel treatments.
This document supplements the discussion with your Bloom Health provider. Please read it thoroughly and ask
any questions before submitting.
I. Botulinum Toxin Type A Neuromodulators
(e.g., Botox®, Dysport®, Xeomin®, Jeuveau®, Daxxify®, and similar products)
Treatment Description & Goals
Neuromodulators temporarily relax targeted muscles to soften expression lines and improve facial harmony.
Common treatment areas include the forehead, frown lines, crow’s feet, chin, lip lines, neck bands, and
masseters. Onset is typically 3–14 days, average duration is approximately 3–4 months, and the goal is
improvement rather than perfection; individual results vary.
Aftercare
- Remain upright for 4 hours after treatment.
- Avoid rubbing or massaging treated areas.
- Avoid strenuous exercise, saunas, or alcohol for the remainder of the day.
- Minor redness, swelling, or bruising may occur and typically resolves on its own.
Risks & Possible Complications
- Redness, swelling, or bruising at injection sites
- Headache or flu-like symptoms
- Uneven results or temporary asymmetry
- Eyelid or brow heaviness (ptosis)
- Temporary weakness of nearby muscles
- Rare allergic reaction
II. Hyaluronic Acid Dermal Fillers
(e.g., Juvéderm®, Restylane®, RHA®, Versa®, Belotero®, and similar HA-based gels)
Treatment Description & Goals
Hyaluronic acid (HA) fillers are injectable gels used to restore volume, contour, and facial balance.
Common areas include the lips, cheeks, chin, jawline, under-eyes, nasolabial folds, marionette lines,
temples, and hands. Results are typically immediate, duration is approximately 6–18+ months depending
on product and area, and HA fillers are reversible with hyaluronidase.
Aftercare
- Avoid pressure or massaging treated areas unless instructed.
- Swelling and possible bruising are common in the first few days.
- Avoid intense heat, strenuous exercise, and alcohol for the remainder of the day.
Risks & Possible Complications
- Redness, swelling, tenderness at injection sites
- Bruising
- Temporary lumps, nodules, or unevenness
- Migration of filler
- Infection
- Rare but serious: vascular occlusion, tissue damage, vision changes or blindness
III. Poly-L-Lactic Acid (PLLA) Biostimulatory Fillers
(e.g., Sculptra® and other PLLA-based products)
Treatment Description & Goals
PLLA fillers stimulate the body’s own collagen production to gradually improve volume, contour, and skin
quality. Results develop over time and typically require a series of treatments. Results are gradual
(usually over 6–12+ weeks) and may last approximately 1–2+ years after a full series. Post-treatment
massage is required as instructed by your provider.
Risks & Possible Complications
- Swelling, tenderness, or bruising
- Nodules or palpable small lumps (early or delayed)
- Asymmetry
- Infection
- Rare granuloma formation
IV. Calcium Hydroxylapatite (CaHA) Biostimulatory Fillers
(e.g., Radiesse® and similar CaHA-based products)
Treatment Description & Goals
CaHA fillers provide structural support and stimulate collagen. They may be used undiluted for volumizing
or hyper-diluted to improve skin quality and texture. Duration varies with area and dilution.
Risks & Possible Complications
- Redness, swelling, or bruising
- Nodules or firmness
- Asymmetry
- Infection
- Rare but serious: vascular occlusion, tissue necrosis, and vision compromise
V. Autologous Injectable Treatments
(PRP, PRF, EZ Gel, PRFM, fibrin matrices, platelet-derived bio-gels, and similar regenerative injectables)
Treatment Description & Goals
Autologous injectable treatments use components of your own blood to support collagen production, tissue
rejuvenation, and improved skin quality. Results are gradual and may require a series of treatments to
achieve optimal outcomes.
Risks & Possible Complications
- Redness, swelling, or bruising
- Mild discomfort
- Temporary unevenness or firmness
- Infection (rare)
VI. Deoxycholic Acid (DCA) Fat-Dissolving Injections
(e.g., Kybella® and similar DCA-based formulations)
Treatment Description & Goals
Deoxycholic acid (DCA) injections are used to reduce small, localized pockets of fat by disrupting fat cells,
which are then gradually cleared by the body. These treatments are most commonly performed in the submental
(under-chin) area and are not a weight-loss procedure. Multiple sessions are often required, swelling can be
significant for several days, and individual results vary.
Aftercare
- Expect noticeable swelling, tenderness, and firmness for several days after treatment.
- Use cold compresses as recommended by your provider.
- Avoid vigorous exercise for the first 24–48 hours.
- Contact Bloom Health promptly if you experience increasing pain, difficulty swallowing, or unusual symptoms.
Risks & Possible Complications
- Swelling, redness, bruising, and tenderness
- Firmness, nodules, or areas of hardness
- Temporary numbness or altered sensation
- Contour irregularities or asymmetry
- Infection
- Temporary nerve irritation, including weakness of the lower lip or smile due to marginal mandibular nerve involvement
- Rare scarring or prolonged changes in sensation
General Expectations & Limitations
Injectable treatments aim to create improvement, not perfection. Results vary based on individual anatomy,
metabolism, lifestyle, and product selection. Maintenance treatments are often required to sustain results, and
no specific outcome can be guaranteed.
Pregnancy & Medical Considerations
By submitting this consent, you confirm that you are not pregnant, breastfeeding, or attempting to conceive;
that you have no active infection in any planned treatment area; and that you have disclosed all relevant
medical history, medications, allergies, and recent procedures to your Bloom Health provider.
Alternatives to Treatment
Alternatives may include medical-grade skincare, chemical peels, microneedling, laser resurfacing,
energy-based tightening, surgical procedures, or choosing no treatment.
Payment
All injectable treatments at Bloom Health are cosmetic and not covered by insurance. Payment is your
responsibility and is due at the time of treatment.
Right to Decline
You understand that you may decline or discontinue treatment at any time.
Release of Liability
You understand these procedures are elective and release Bloom Health, PLLC, and its providers from liability
associated with these treatments, to the extent permitted by law.
Consent to Treatment
By entering your initials and submitting this form, you voluntarily consent to receive injectable treatments such
as botulinum toxin neuromodulators, hyaluronic acid fillers, PLLA biostimulatory fillers, CaHA biostimulatory
fillers, deoxycholic acid fat-dissolving injections, and autologous injectable treatments
(including but not limited to PRP, PRF, EZ Gel, PRFM, and similar platelet-derived or autologous bio-gel treatments)
at Bloom Health. By submitting this form, you also acknowledge that you have read and understand the information in this consent
form, that all of your questions have been answered to your satisfaction, that you are not under the influence
of drugs or alcohol while providing consent, that you understand the potential risks, benefits, and alternatives
of these elective procedures, and that this consent applies to all future injectable treatments you choose to
receive at Bloom Health, unless revoked in writing.
