Informed Consent for Fillers Treatment

I Mr./Ms./Mrs._____________________________have been informed and I understand

to my satisfaction about Filler’s treatment, its indication and what it entails.

I have been specifically informed that there is potential side effect associated with
implantation of this product, which may occur immediately or may be delayed, these
include:
1. Inflammatory reactions (redness, edema, erythema, etc.) which may be associated
with itching, pain on pressure or both, occurring after the injection. These reactions
may last for a week.
2. Hematomas
3. Indurations or nodules at the injection site.
4. Staining or discoloration in the injection site.
5. Poor effect or weak filling effect.
6. Tissue compromise in the glabellar region, abscesses, granuloma and immediate or
delayed hypersensitivity.

In the majority of the cases have been described as mild to moderate and typically
resolve spontaneously a few days after injection.

l am also informed that depending on the individual, the area and the specific product
used, the effect of the treatment may last up to 6-12 months with exceptions. Touch-up
follow-ups may be needed to sustain the desired degree of correction.

I consent to take photo of the areas to be treated for medical records purposes.

Patient name & signature:

Doctor name & signature:
Witness name & signature: