Dermal Filler Informed Consent Form (Page 2 of 2) in pdf

Dermal Filler Informed Consent Form Page 2

The number of units injected is an estimate of the amount of dermal filler required to add volume to

the skin and give the appearance of a smoother face. I understand there is no guarantee of results

of any treatment and the regular charge applies to subsequent treatments.

I understand and agree that all services rendered are charged directly to me and I am personally

responsible for payment. I further agree in the event of non-payment, to bear the cost of collection,

attorney fees and/or Court costs and reasonable legal fees, should this be required. By signing

below, I acknowledge that I have read the foregoing informed consent and agree to the treatment

with its associated risks. I will follow all after care instructions as it is crucial for healing. I hereby

give consent to perform this and all subsequent dermal filler treatments with the above

understood.

I have read this informed consent and certify that I understand its contents in full.

_________________________________________________________________________________Date_________________________

Patient signature/legally authorized representative

________________________________________________________________________________Relationship________________

Printed name if signed on behalf of the patient

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Dermal Filler Informed Consent Form Page 2