The purpose of this informed consent form is to provide a written copy of the information your doctor or medical technician discussed with you regarding the risks, benefits and alternatives of the treatment named above, and to document your consent to this treatment. This document serves as a supplement to the discussion you have with your doctor or medical technician. It is important that you fully understand this information, so please read this document thoroughly.
Please initial every paragraph of this form that has the words "Initial " to confirm that you
have read and understood that paragraph. If you do not understand or accept any paragraph, please advise your doctor or medical technician and do not place your initials on this form. If you have any questions regarding the treatment, ask your doctor or medical technician prior to signing the consent form. You may withdraw consent at any time by telling the doctor or medical technician performing the treatment.
Dermal fillers (such as Juvederm, Restylane, Teosyal and others) can smooth out facial folds and wrinkles, add volume to the lips, and contour facial features that have lost their volume and fullness due to aging, sun exposure,
illness, etc. Dermal fillers are temporary injectable implants made from hyaluronic acid and may also include numbing agents such as lidocaine. These dermal fillers are injected under the skin with a very fine needle and the area is massaged to ensure optimal placement. Depending on the area of treatment, several injections may be
required. As with any injection, you may experience some temporary discomfort but most patients find the treatment tolerable. The results can often be seen immediately and no recovery time is required. Your treatment may be performed by a doctor or a medical technician.
You are aware that this treatment involves the injection of a temporary implant below the skin and that several injections may be required. You are aware that your treatment may be performed by either a doctor or a medical technician.
This treatment should not be performed at the same time as other skin treatments such as chemical peels, dermabrasion, or laser treatments and a minimum of two weeks is required in between treatments. This treatment may not be suitable for those who have had or plan to have facial surgery.
Dermal fillers are used to produce volume under the skin to make areas such as cheeks and lips appear fuller, to lift and smooth wrinkles and folds. Dermal fillers are approved by Health Canada and have been shown to be safe and effective when compared to collagen skin implants and related products to fill in wrinkles, lines and folds in the skin on the face. However, like any cosmetic treatment, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatment to achieve the results you seek. The effects of this treatment are dependent on many factors, including but not limited to age, sex, tissue conditions, general health and lifestyle conditions, and sun exposure. Dermal fillers are non-permanent because the body absorbs hyaluronic acid slowly over time. Additional treatments will be required periodically, generally within 4-6 months, for the effect to continue. Following post-treatment care, instructions provided by your doctor or medical technician are recommended to maximize your results.
You are aware that follow-up treatments will be needed to maintain or enhance the effects of this treatment. You are aware that the effects of treatment, depending on the above-listed factors, may last up to 6 months and in some cases shorter and some cases longer. You have been instructed in and understand the post-treatment instructions.
RISKS AND COMPLICATIONS
Before undergoing this treatment, understanding the risks is essential. No treatment is completely risk-free. Below is a list of the known risks of this treatment but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may require hospitalization or extended outpatient therapy to treat.
There are certain inherent and potential risks and side effects in any invasive treatment and in this specific instance such risks include but are not limited to:
1) Post-treatment discomfort, swelling, redness, bruising, and discoloration;
2) Post-treatment infection associated with any transcutaneous injection;
3) Allergic reaction;
4) Reactivation of herpes (cold sores);
5) Lumpiness, visible yellow or white patches;
6) Granuloma formation;
7) Blood vessel occlusion causing localized necrosis and/or sloughing of skin, with scab and/or without a scab.
You are aware that this treatment has a risk of side effects, some of which may be unforeseen and are not listed above. You are aware that some side effects may be serious and require hospitalization or extended medical treatment. You understand that by choosing to undergo this treatment, you are accepting these risks.
PREGNANCY, ILLNESS AND ALLERGIES
This treatment should not be performed on women who are pregnant, intend to become pregnant or are nursing. This treatment should not be performed by anyone who has multiple allergies or high sensitivity to medications, including but not limited to hyaluronic acid or lidocaine. This treatment may not be suitable for patients who have or have had major illnesses. All major illnesses or allergies should be disclosed to the doctor or medical technician prior to signing this consent form.
You are not pregnant, do not intend to become pregnant and are not nursing. You do not have multiple allergies or high sensitivity to medications, including hyaluronic acid and lidocaine. You have disclosed any major illnesses to the doctor or medical technician performing this treatment.
There are alternative cosmetic, medical and surgical treatments that may be used to reduce the look of fine lines and wrinkles or to add volume to the face or lips. If you wish to discuss alternative treatments please ask the doctor or medical technician prior to signing this consent form.
You have discussed alternative treatments with the doctor or medical technician performing this treatment and have had an opportunity to ask any questions you may have about these alternatives.
This treatment is an elective cosmetic treatment not covered by the Ontario Health Insurance Plan ("OHIP"). Payment is expected at the time of treatment and you will be provided with an invoice or receipt for your records. The cost of treatment should be discussed with your doctor or medical technician prior to signing this consent form. Initial
You are aware that this treatment is not covered by OHIP and that payment is expected at the time of treatment. You are aware of and agree to pay the cost of treatment.
For the purpose of adequate record keeping, your doctor or medical technician will take close-up photographs of the treatment area(s) before, during, and after treatment. These photos are taken for the sole purpose of supporting
your care and treatment. These photos will form part of your medical record will be treated with the same confidentiality as other medical records.
You are aware that photos of the treatment area will be taken before, during, and after your treatment.
You are aware that these photos will be maintained in your medical record.
RIGHT TO DISCONTINUE TREATMENT
You have the right to discontinue treatment at any time by telling the doctor or medical technician performing the treatment If you have questions or concerns during the treatment, please inform the doctor or medical technician performing the treatment.
You are aware that you have the right to discontinue treatment at any time.
CONFIRMATION OF UNDERSTANDING
It is important that you understand this consent form and all of the information provided to you.
You are able to read and write in English and have read the above consent form and understand it. You have been told that you have the right to ask questions about the treatment and about this consent form. All of your questions have been answered to your satisfaction.
STATEMENT OF CONSENT
By signing this form, you confirm that you are aware that this is an elective cosmetic treatment and hereby voluntarily consent to treatment with dermal fillers for facial rejuvenation, lip enhancement, and/or replacing facial volume. The treatment has been fully explained to you including risks and potential side effects. You have had the opportunity to ask any questions you may have and those questions have been answered to your satisfaction. You accept the risks and complications of the treatment and you understand that no guarantees are implied as to the outcome of the treatment. If you have any post-treatment questions or concerns, or changes in your medical history, you will notify the doctor or medical technician who treated you immediately.
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