Filler Consent Form Patient Name* First Last INSTRUCTIONS This document will inform you about the non-animal stabilized hyaluronic acids, their risks, and alternative treatments. It is important that you read this information carefully and completely. Please sign each page, indicating that you have read that page.GENERAL INFORMATION Hyaluronic acids used to smooth moderate to severe facial wrinkles and folds or shape facial contours. They have been FDA approved for the cosmetic treatment of moderate to severe facial wrinkles and soft tissue depressions. Hyaluronic acid is a naturally occurring substance that is found in human soft tissues. Dermal fillers are hyaluronic acids that have been synthetically produced by a process of bacterial fermentation, then chemically stabilized and purified. The hyaluronic acid found in dermal fillers is biocompatible and not an animal product, so there is little risk of animal-based disease transmission or allergic reactions. Dermal filler injections are customized for each patient, depending on his or her particular need and can be performed in multiple areas of the face. These fillers cannot stop the process of aging. They can, however, temporarily diminish the appearance of wrinkles and soft tissue depressions. Dermal filler injections may be performed alone or in combination with each other or with treatments such as Botox or Xeomin. Dermal filler injections may require the use of regional nerve blocks or topical anesthetic application to diminish discomfort. Soft tissue fillers produce temporary swelling, redness and needle marks, which resolve after a few days. Continuing treatments are necessary in order to maintain the effect of dermal fillers over time. After these fillers are injected, they will be slowly absorbed by the body. The duration of the effect of dermal filler is variable.ALTERNATIVE TREATMENTS Alternatives to using hyaluronic acids, such as dermal fillers, include not treating skin wrinkles or soft tissue depressions by any means, treating them with lasers, chemical peels, dermabrasion, non-hyaluronic acid fillers or surgery. Risks and potential complications are also associated with these alternative forms of medical and surgical treatment.THE IMPORTANCE OF YOUR UNDERSTANDING TREATMENT RISKS It is important that you understand the risks and benefits of treatment with dermal fillers because your choice to undergo such treatment is based on the comparison of these risks to the potential benefits. Additional information may be obtained from the package-insert sheets supplied by Allergan.Signature*Date* Date Format: MM slash DD slash YYYY NORMAL OCCURENCES DURIG DERMAL FILLER INJECTIONS Bleeding and Bruising – It is possible, though unusual, to have a bleeding episode from an injection. Should you develop post-injection bleeding, emergency treatment or surgery may be necessary. Bruising in soft tissues may also occur. Aspirin, anti-inflammatory medications, platelet inhibitors, anticoagulants, Vitamin E, ginko biloba and other “herbs/homeopathic remedies” may increase the risk of bleeding and bruising. Do not take any of these products for seven days before dermal filler injections unless you have been advised to do so by your cardiologist or primary care physician. Swelling – Swelling (edema) is a normal occurrence following the injection of dermal fillers. It usually decreases after a few days, but if it slow to resolve, medical treatment may be necessary. Erythema (Skin Redness) – Erythema occurs in the skin after injections. It can be present for a few days after the procedure. Needle Marks – Visible needle marks from injections occur normally and resolve in a few days. Acneiform Skin Eruptions – Acne-like skin eruptions can occur following the injection of dermal fillers. These generally resolve within a few days. Skin Lumpiness – Lumpiness can occur following the injection of dermal fillers. This tends to smooth out over time. In some situations, it may be possible to feel the injected tissue filler material for long periods of time. While feeling lumps is to be expected, seeing lumps is not. Sometimes bruises create lumps and these will resolve on their own: however, if the filler is causing a visible lump, there is a 2 week period in which it can be smoothed. Please do not hesitate to contact me to discuss this if you are unsure. Visible Tissue Filler – It may be possible to see dermal fillers through the skin if it is injected into areas where the skin is thin. Asymmetry – The human face is normally asymmetrical in its appearance and structure. It may not be possible to achieve or maintain exact symmetry with tissue filler injections. There can be a variation from one side to the other after dermal filler injections. This may require additional injections. Pain – Discomfort associated with dermal filler injections is normal and usually of short duration. Skin Sensitivity – Skin rash, itching, tenderness and swelling may occur following dermal filler injections. After treatment, you should avoid exposing the treated area to excessive sun, UV lamps and extremely hot or cold temperatures until any initial swelling or redness has gone away. If you were to undergo laser treatment, chemical peels or any other procedure after dermal filler injections, there is a possible risk of an inflammatory reaction at the implant site. Signature*Date* Date Format: MM slash DD slash YYYY RISKS OF DERMAL FILLER INJECTIONS Accidental Intra-Arterial Injection – Dermal filler can accidentally be injected into arteries and block blood flow. This could cause necrosis (death) in facial skin and other structures, loss of vision or other unknown consequences. This is a very serious, but rare occurrence. Damage to Deeper Structures – Deeper structures such as nerves and blood vessels may be damaged during the course of dermal filler injections. Injury to deeper structures may be temporary or permanent. Infection – Bacterial, fungal, and viral infections can occur following injections with dermal filler. One such infection is the reactivation of the herpes simplex virus commonly referred to as a cold sore. This can occur both in individuals who have had prior cold sores and those who have not. Please ask Staff for a Valtrex prescription if you plan to have an injection in an area where you have had a prior cold sore. Should any other type of skin infection occur, additional treatment including antibiotics may be necessary. Allergic Reactions and Hypersensitivity – As with all biologic products, allergic and anaphylactic reactions may occur. You should not have injections with dermal fillers if you have a history of multiple severe allergies, a history of anaphylaxis or allergies to gram-positive bacterial proteins. Allergic reactions may require additional treatment. Scarring – It is possible that injections with dermal fillers, could promote excessive scar formation so you should not receive these injections if you have a history of keloid formation or other forms of excessive healing at scars sites. Granulomas – Granulomas are masses that the body forms akin to scar tissue. Rarely, these may occur in the skin and deeper tissues after a dermal filler injection. Should a granuloma develop, additional treatments including surgery may be necessary. Skin Disorders – In rare instances, abscess, localized necrosis (skin death) and urticaria have occurred after dermal filler injections into areas with active inflammation or infection (e.g. cysts, pimples, rashes or hives). Antibodies to Fillers – If antibodies form to dermal fillers, this could reduce the effectiveness of this material or produce a reaction in subsequent injections. The health significance of antibodies to hyaluronic acid tissue fillers is unknown. Anesthetic Reactions – It is possible to have a reaction to the anesthetic applied or injected before treatment or from the lidocaine anesthetic mixed in with dermal filler. Such reactions include light-headedness, rapid heart rate (tachycardia) and fainting. Medical treatment of these conditions may be necessary.Signature*Date* Date Format: MM slash DD slash YYYY UNKNOWN CONSEQUENCES OF TREATMENT Combination of Procedures –The long term effect of combining injections of dermal filler with each other or other treatments (for example: non-hyaluronic acid fillers, Botox, laser, microdermabrasion, chemical peels or others) is unknown. Unknown Risks – The long term consequences of injecting dermal fillers are unknown. It is possible that complications may arise from the use of dermal fillers that are unknown and cannot be predicted. Pregnancy and Nursing Mothers – It is not known if dermal fillers are safe during pregnancy or if their breakdown products are excreted in human milk. Because the risk is unknown, pregnant women and nursing mothers should not receive dermal filler injections. If you are pregnant or breast feeding now or at a future time that you desire injections, please inform Staff. Drug Interactions – It is not known if dermal fillers react with other drugs within the body.DISAPPOINTING RESULTS Under/Over Correction – Injection of dermal fillers may not achieve your desired outcome. The amount of correction may be inadequate or excessive. If under correction occurs, you may be advised to consider additional injections of filler. Migration of Filler – Dermal fillers may migrate from their original injection site and produce visible fullness in adjacent tissue or other unintended effects. Unsatisfactory Result – The injection of dermal fillers may not result in the outcome you expect. It is possible that your tissue’s response may be poor or inadequate. Additional dermal filler injections or surgery may be necessary to achieve your desired result.TREATMENT IS NOT PERMANENT Dermal filler injections should not be considered permanent treatment for the correction of wrinkles and soft tissue depressions. Over time, the dermal fillers are slowly absorbed by the body and wrinkles or soft tissue depressions will reappear. It is necessary to continue to receive injections of filler to maintain the effect. Despite such injections, alterations in the face may still occur as the result of aging, weight loss or gain, sun exposure, or other circumstances and may necessitate future surgery or other treatments. Dermal filler injections do not arrest the aging process or produce permanent tightening of the skin or improvement in wrinkles.Signature*Date* Date Format: MM slash DD slash YYYY DISCLAIMER – This document is designed to inform you about dermal filler injections and disclose the associated risks and alternative forms of treatment. It should not be regarded as all-inclusive because it is not possible to anticipate all risks and alternative forms of treatment. This document is not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve.It is important that you have read all of the above information carefully and have all of your questions answered before signing this consent form. 1. I HEREBY AUTHORIZE FUSION MEDICAL AESTHETICS to inject dermal filler selected by Staff. 2. I consent to the administration of anesthetics and understand that all forms of anesthesia involve risk and possible complications include injury and rarely death. 3. I am aware that dermal filler can contain Lidocaine. 4. I acknowledge that no guarantee has been given by anyone as to the results that may be obtained. 5. I understand that there are alternative methods of treatment. 6. I understand that there are risks to the proposed treatment.Signature*Date* Date Format: MM slash DD slash YYYY PHOTO RELEASE CONSENT I consent to the taking of photographs by Dr. Lisa Gardner or her designee of me or parts of my body in connection with the aesthetic procedure(s) to be performed. I provide this authorization as a voluntary contribution in the interests of public education. I understand that such photographs shall become the property of Fusion Medical Aesthetics and may be retained by Fusion Medical Aesthetics or released by Fusion Medical Aesthetics for the limited purpose of including them in any print, visual or electronic media, specifically including, but not limited to, medical journals and textbooks, for the purpose of informing the medical profession or the general public about aestehtic procedures and methods. Neither I, nor any member of my family, will be identified by name in any publication. I understand that in some circumstances the photographs may portray features that will make my identity recognizable. I understand that I may refuse to authorize the release of any health information and that my refusal to consent to the release of health information will prevent the disclosure of such information, but will not affect the health care services I presently receive, or will receive, from Fusion Medical Aesthetics. I understand that I have the right to inspect and copy the information that I have authorized to be disclosed. I further understand that I have the right to revoke this authorization in writing at any time, but if I do so it won’t have any affect on any actions taken prior to my revocation. If I do not revoke this authorization, it will expire ten years from the date written below. I understand that the information disclosed, or some portion thereof, may be protected by state law and/or the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). I further understand that, because Fusion Medical Aesthetics is not receiving the information in the capacity of a health care provider or health plan covered by HIPAA, the information described above may no longer be protected by HIPAA. I release and discharge Dr. Lisa Gardner, Fusion Medical Aesthetics, and all parties acting under their license and authority from all rights that I may have in the photographs and from any claim that I may have relating to such use in publication, including any claim for payment in connection with distribution or publication of the photographs. I certify that I have read the above Authorization and Release and fully understand its terms.*I consent to my photo(s) being taken.I DO NOT consent to my photo(s) being taken.