Dermal Filler Informed Consent

Treatment Overview

Dermal fillers (e.g., hyaluronic acid fillers) are injected to restore volume, enhance facial features, and improve contour and symmetry.

Results are temporary and vary by product and individual.

I understand the nature and temporary duration of treatment.Initials

Common Risks & Side Effects

• Bruising, swelling, redness, tenderness
• Lumps, bumps, or irregularities
• Asymmetry or need for additional product
• Infection or delayed swelling

I understand common risks.Initials

Serious Risks (Rare but Important)

• Vascular occlusion (blockage of a blood vessel)
• Skin necrosis (tissue damage)
• Vision changes or blindness
• Stroke (extremely rare)

I understand serious risks including blindness.Initials

Emergency Treatment Consent

If a vascular complication is suspected, I consent to immediate treatment, which may include hyaluronidase injections and/or referral to a higher level of care.

I consent to emergency treatment if needed.Initials

Medical Disclosure

• I have disclosed all medical conditions, medications, supplements, and allergies.
• I am not pregnant or breastfeeding unless discussed with my provider.
• I will inform my provider of any history of herpes simplex (for lip treatments).

I have fully disclosed my medical history.Initials

Alternatives & No Guarantee

• Alternatives include no treatment, skincare, or surgical options.
• No guarantee has been made regarding results; additional sessions may be required.

I understand alternatives and no guarantee.Initials

Financial Policy

All sales are final. No refunds once product is injected. Touch-ups are subject to provider assessment and timing.

I agree to the financial policy.Initials

Consent & Signatures