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INFORMED CONSENT – HYALURONIC ACID INJECTIONS (fillers)

This consent form is designed to give you the information you need to make an informed decision about whether or not to undergo treatment with Hyaluronic acid dermal filler for facial wrinkles and folds, contour defects, and/or lip enhancement. If you have any questions, please ask Jen Beauty By Jen.

INTRODUCTION

Hyaluronic acid treatments involve injection of purified hyaluronic acid into the skin to fill wrinkles and restore volume. No skin testing is needed prior to treatment. Just like natural hyaluronic acid, injectable Hyaluronic acid eventually loses its form and wears down. The effects of injectable Hyaluronic acid can last 6 months or longer and ongoing treatments are required to maintain the improvements. However, due to various factors that influence Hyaluronic acid breakdown, no guarantees can be made regarding how long correction will last in a specific patient.

PATIENTS THAT MAY NOT BE ELIGIBLE FOR HYALURONIC ACID TREATMENTS

Patients with the following conditions may not receive Hyaluronic acid treatments: previous allergic reactions to injectable hyaluronic products, history of a serious allergic reaction (anaphylactic), multiple severe allergies, abnormal raised scarring or keloid formation, active inflammation, infection in the treatment area (e.g. pimples, rash, hives), pregnancy, or nursing or recent dental/facial surgery. Individuals who have recurrent viral infections such as herpes simplex (cold sores) as it may be activated by Hyaluronic treatments. The injectors must be notified of these conditions prior to treatments.

Getting ready for your procedure Do’s and Don’ts

• Trust is a big factor, you must trust the stylist who is completing your treatment. Beauty by Jen is trained in Hyaluronic acid fillers. Jen will help you through the process with explaining what to expect during the procedure. 


• Ice the treatment area for the first 2 days


• Often swelling can occur post treatment, although this will vary depending on the individual. The tear trough area is also more likely to swell than other areas. The application of ice to the treated area will help to reduce swelling, redness and any bruising, especially the next day! 


• No make up can be worn for 5-7 days after procedure


• Maintenance appointments, or top-ups, before your results completely wear off can lengthen and enhance the dermal filler’s effects. It is often better to preserve the results rather than start from scratch once all the hyaluronic acid has been broken down. Dermal filler can also be used in conjunction with other treatments to help prevent effects from fading.  


• Before any injectables treatment, ensure you stay hydrated by drinking plenty of water. This is the same for after your treatment. Increased hydration will ensure you avoid excess swelling to the treated area.  


• No Inflammatories pills are allowed to be taken 2-3 days prior to procedure after the procedure for 5-7 days (includes Ibuprofen)


• No washing your face after your filler. It is important to not get the area wet if possible for 5 days. 


• No being in sunlight for 7 days after Procedure alway wear sunscreen if you go out a lot 


• Realistic expectations will help achieve your desired outcome. If you trying to enhance a particular area, talk to Jen about how you can achieve a natural look that is right for you. Often multiple smaller treatments can have a better effect than large treatments in the healing process.


• Dermal filler cannot be administered to clients who are either pregnant or breastfeeding. 


• There should be no alcohol consumption at least 24 hours pre or post your dermal filler treatment. The intake of alcohol can increase inflammation so stay hydrated with other alternatives that will enhance the healing process.  


• Exercise may result in additional bruising or swelling of the treatment area, so it is advised to avoid any intense exercise for the first 24 hours post treatment.  

RISKS

The possible risks, side effects, and complications with Hyaluronic acid include, but are not limited to:

1. Pain and tenderness during and after treatments at/around the treated site that typically resolves within a few days to a week.


2. Redness and swelling at/around the injection site is common. Itchiness may also occur. These reactions are generally present immediately after treatment and lessen or disappear within a few days to 1 week. Some patients may experience prolonged swelling and/or tenderness/pain at the injection site lasting up to 2 weeks. Some patients may experience a delayed onset of these symptoms up to several weeks after treatment. On rare occasions, pustules (acne-like lesions) may form. The injector must be notified if symptoms persist for more than 1 week. Bruising which usually resolves within 1-2 weeks after the injection. Patients taking medications that interfere with coagulation (e.g. aspirin, ibuprofen) have an increased risk of bruising and bleeding.


3. Infection at the treated site. This may require antibiotics and, rarely, open drainage.


4. Although rare, local tissue damage can occur with skin breakdown, scab formation, and/or scarring in the treated area.


5. Visible raised areas and lumpiness at/around the treated site grayish discoloration of the skin. These symptoms may persist from a few weeks to several months and may be permanent (rarely).


6. Failure to reduce a contour defect or wrinkle (under correction) or overcorrection. Placement of filler adjacent to or outside the desired treatment area; undesired changes in facial contour. Asymmetry, where the correction on one side may be different from the correction on the other side of the face. Swelling at time of injection my created the appearance of asymmetry or under correction with usually resolves as described above. However, you may need to return for additional treatment if under correction or asymmetry persists.


7. Hyaluronic acid may have an unpredictable duration of action and may not last as long as anticipated or may persist in some areas longer than anticipated.


8. A remote and rare risk is that of injection of Hyaluronic acid into a blood vessel which can block blood flow in the treated area or in distant areas causing tissue damage which may require surgical correction.


9. All the risks of Hyaluronic acid may not be known. Dr. Lacey and his staff are not responsible for any Hyaluronic acid risk or unforeseen complication not yet discovered or not commonly known. 

I consent to administration of any related treatments that may be deemed necessary or advisable for this procedure. This includes, but is not limited to, local anesthetic such as lidocaine. The risks, side effects complications of these anesthetics include, but are not limited to, skin irritation (itching or redness), and tongue numbness. I do not have an allergy to lidocaine or anesthetics. 

No guarantees can be made or have been made that I will benefit from treatment or achieve a desired level of correction. There is no guarantee wrinkles or folds will be reduced. I understand that I may require additional treatments to achieve correction. I understand that the fees for hyaluronic acid treatments are not covered by insurance. Should I require a touch-up treatment, I am responsible for the cost of that additional treatment. 

I consent to having my photos taken before and after treatment. These photos are part of my medical record.

I have fully disclosed all my medical history. I understand that it is my responsibility to inform and update of any change in my health status and medical history.

I am an adult of at least 18 years of age. My signature below certifies that I have fully read this consent form and understand the information provided to me regarding the proposed procedure. I have been adequately informed about the procedure involving the potential benefits, limitations and alternative treatments. I have had enough time to consider the information, and I have had all questions and concerns answered to my satisfaction. I understand and accept the risks, side effects, and possible complications associate with Hyaluronic acid treatment.

I consent and authorize Jen Hendren to perform Hyaluronic acid injection treatments. This consent shall apply to all future Hyaluronic Acid treatments. Should I have any questions or problems after treatments, I will call the Jen at (480) 310-0431

I have been informed in a way that I understand:

1. The above treatment or procedure to be undertake


2. There are risks to the procedure or treatment proposed

By signing this form I consent and understand all the above information and I am satisfied with the explanations.