Informed Consent Form For The Temporary Treatment With Injectable Dermal Fillers


My signature and initials after each statement below constitutes my acknowledgment that:
I, ____________________________________, consent to and authorize David Thomas, MD or Catherine Voci,
WHNP-BC, DNP to perform injections with injectable fillers to improve the appearance of facial defects, scars, and/or
wrinkles, or to have my lips augmented (made larger). The fillers to be used include Prevelle Silk, Restylane, and/or
 The area to be treated ____________________________________________________
 The filler to be used is ____________________________________________________
1. The nature and purpose of the treatment has been explained to me and questions I have regarding the
treatment have been answered to my satisfaction. _________
2. I am fully aware of the risks of complications or injuries that can occur from this treatment, both from known and
unknown causes, and I freely assume those risks. __________
The known complications could include:
 Redness, swelling/edema, itching, pain or pressure lasting more than one week
 Nodules or induration at the injection site
 Discoloration at the injection site
 Poor effect or weak filling
 Allergic reactions
3. I also certify that I have none of the known conditions that would contraindicate treatment. These conditions
include hypertrophy scars, a history of any autoimmune disease, or immune therapy. I am not pregnant,
breast-feeding, and I have no known allergy to hyaluronic acid or collagen. _________
4. I certify that I have read this entire informed consent and that I understand and agree to the information stated
in this form. I certify that I am a competent adult of at least 18 years of age, or that if I am a minor under the
age of 18, I understand that the consent of a parent/legal guardian will also be required before treatment. This
informed consent is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal
representatives, heirs, administrators, successors, and assigns. __________


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