Dermal Filler Informed Consent Form printable pdf download

Dermal filler informed consent

I understand that I will be injected with ________________________dermal filler, in the following areas:

______________________________________________________________________________________________________________

The indicated dermal filler has been FDA approved for use in cosmetic treatment for moderate to

severe wrinkles around the nose and mouth. I understand this treatment is temporary and

re-injection is necessary after about six months. It has been explained to me that other temporary

and more permanent treatments are available. I have chosen this type of treatment after discussing

the options with my dentist and am proceeding voluntarily.

The following risks and complications may occur with the dermal filler injection procedure:

Bruising, redness, swelling, pain at the injection site, tenderness, itching, allergic reaction,

and raised bumps of skin (nodules). These symptoms are usually mild and typically last a

few days but can last up to a few months. In rare cases, bruising can last several months

and even be permanent.

Infection: Post treatment bacterial, viral and/or fungal infections can occur, which in most

cases are easily treatable but in rare cases cause permanent scarring in the area.

Effectiveness: Treatments can last anywhere from 4 months up to one year.

Treatments: I understand more than one injection may be needed to achieve a satisfactory

result.

Allergic Reactions: In rare cases, there may be an allergic reaction to the injection.

There is a risk of permanent scarring.

As dermal fillers are not an exact science, there might be an uneven appearance of the face with

some areas more affected by fillers than others. In most cases, this uneven appearance can be

corrected by more injections in the same or nearby areas. However, in some cases this uneven

appearance can persist for several weeks, months, or in rare occasions permanently.

This list is not meant to be inclusive of all possible risks associated with dermal fillers, as there are

both known and unknown side effects associated with any medication or procedure.

These dermal fillers should not be administered to a pregnant or nursing woman. Initial below as

appropriate:

__________ I am pregnant.

__________ I am not pregnant.

__________ I am unsure whether I am pregnant.

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Dermal Filler Informed Consent Form