1661 International Dr ,Suite 400, Memphis, TN 38120

800-475-1182

CONSENT TO DERMAL FILLER TREATMENT
(Juvederm family, Restylane family, others)

Injectable fillers are a minimally invasive treatment to correct many of the signs of aging. They can make significant improvement with minimal downtime.
Both Juvederm & Restylane are cosmetic dermal fillers which come as smooth consistency gel that replace lost volume and restore youthful contours to the skin. .
Dermal fillers are made of non-animal-based hyaluronic acid, a natural substance (Complex Sugar) that already exists in the human body . NASHA is completely biocompatible with human hyaluronic acid, therefore no allergy testing is required. This replaces lost volume and restores youthful contours to the skin to smooth away moderate to severe facial wrinkles.

Areas most frequently treated are: nasolabial folds, oral commissures, lips, and Glabellar among others. Patient may experience a slight burning sensation during injections. The procedure takes about 5 -20 minutes. Results typically can last six months to two years depending on the nature if the filler.

THE PROCEDURE
The procedure is relatively simple, and will be performed by the Doctor or Nurse Practitioner or Physician Assistant and finished in a few minutes. Treatment can be administered without anesthetic, but if you are sensitive to needles, you can request that a numbing agent be used on the skin. The doctor will inject the filler gel under the skin (deep dermis or subcutaneous) with a fine needle. Where the gel is injected depends on the desired results, as does the number of injections and the amount of filler used. A typical treatment lasts ten minutes to twenty minutes depending on how many injections are administered.

PRETREATMENT INSTRUCTIONS

To minimize the risk of bruising, three days before the procedure hold blood thinning over-the-counter medications such as Aspirin (unless medically necessary), Motrin, Ibuprofen, and Aleve. Also avoid herbal supplements, such as Garlic, Vitamin E, Ginkgo Biloba, St. John’s Wort, kavakava and Omega-3 capsules.

Do not drink alcoholic beverages 24 hours before (or after) your treatment to avoid extra bruising. ·
Inform your provider if you have a history of Perioral Herpes to receive advice on antiviral therapy prior to treatment.
Inform your provider if you are on Warfarin (Coumadin) , Xarelto, Eliquis or any other prescription anticoagulants. These medications should be continued and should NOT be held prior to the procedure. Provider just needs to be informed.
RESULTS / POST PROCEDURE CARE

Small amounts of hyaluronic acid product are injected in the second layer of skin or under it in the connective tissue spaces which serves to fill lines or plump the intended areas.. About 80% results are immediate. There can be some inflammation seen up to two- or three-days post procedure. applying ice post procedure can reduce or prevent the swelling.
It usually takes 10 to 14 days to fully settle into your skin as it continues to hold more water between its molecules smoothing out and plumping the area.

RISKS AND COMPLICATIONS

It has been explained to me that although this procedure is minimally invasive, there are certain inherent and potential risks and side effects related to this procedure including but are not limited to: 1) Post treatment discomfort, swelling, redness, and bruising, 2) Post treatment bacterial, viral, and/or fungal infection requiring further treatment, 3) Blue discoloration due to filler injected too superficially 4) Very rarely small arterial embolization.

PREGNANCY, OTHER ILLNESSES
I am not aware that I am pregnant, I am not known to have any severe bleeding or clotting disorders or autoimmune conditions, or have any severe allergies.

PAYMENT

I understand that this procedure is cosmetic and that payment is my responsibility. The government insurance plans and most commercial plans will not cover the cost of cosmetic filler treatments . In a very small number of individuals, the injection does not work as satisfactorily or for as long as usual for which no total or partial refunds will be issued.

I hereby voluntarily consent to treatment with Dermal Filler injection for my esthetic needs. The procedure has been explained to me. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure.

Golden Face