Dermal Filler Consent

This consent form is designed to give you the information you need to make an informed decision about whether or not to undergo treatment with dermal fillers (“fillers”). Dermal fillers include hyaluronic acid (Restylane, Hylaform, Hylaform Plus, Captique, Juvederm); calcium hydroxylapatite (Radiesse, Radiance); collagen (CosmoDerm, CosmoPlast, Evolence) or other

Dermal filler treatments are used for the treatment of facial creases, wrinkles, folds, contour defects, depression scars, facial lipoatrophy (loss of fat); and/or lip enhancement. If you have any questions, please ask the physician or nurse from RSMD Medical Spa.

Dermal filler treatments involve multiple small injections of the filler into or below the skin to fill wrinkles and restore volume. No skin testing is needed prior to treatment for the following fillers: hyaluronic acid, purified human-based collagen and Radiesse.

The effects of injectable fillers are temporary as they eventually lose their form and wear down. Ongoing filler treatments are required to maintain the improvements achieved. Typically, hyaluronic acid can last 6 months or longer, collagen can last 4 months or longer (with CosmoDerm often lasting 2 - 3 month) and Radiesse can last 9 months or longer. However, due to various factors that influence the breakdown of dermal fillers, no guarantees can be made regarding how long correction will last in a specific patient.

Patients with the following conditions may not receive filler treatments: history of a serious allergic reaction (anaphylactic), multiple severe allergies, abnormal raised scarring or keloid formation, active inflammation or infection in the treatment area (e.g., pimples, rashes or hives), pregnancy or nursing; allergy to lidocaine or any "caine" anesthetic.

Patients with previous allergic reaction to injectable hyaluronic products (Restylane, Hylaform, Hylaform Plus, Captique, Juvederm) may not receive hyaluronic acid treatments. Patients with previous allergic reaction to calcium hydroxylapatite (Radiesse, Radiance) may not receive Radiesse treatments. Patients with the following conditions may not receive Collagen treatments: previous allergic reaction to injectable collagen products (CosmoPlast, CosmoDerm, Evolence) or undergoing or planning to undergo desensitization injections to porcine or other meat products.

Certain conditions require caution with injectable fillers and may preclude a patient from receiving treatment: poor healing (due to diabetes or other conditions); long-term use of prednisone or other steroid therapy. Recurrent viral infections such as herpes simplex (cold sores) may be activated by filler treatments and a medication can be prescribed prior to your treatment to help prevent a herpes outbreak. The physician or nurse must be notified of these conditions prior to treatments.

Possible risks, side-effects and complications with dermal fillers include, but are not limited to:

Pain and tenderness during and after treatments at/around the treated site, typically resolving within a few days to 1 week.
Redness and swelling at/around the injection site are common. Itchiness may also occur. These reactions are generally present immediately after treatment and lessen or disappear within a few days to 1 week. Some patients may experience prolonged swelling or tenderness/pain at the injection site lasting up to 2 weeks. Some patients may experience a delayed onset of these symptoms, up to several weeks after treatment. Dr. Small must be notified if symptoms persist for more than 1 week or if symptoms appear in a delayed fashion after treatment.
Bruising usually resolves within 1-2 weeks after the injection. Patients taking medications that interfere with coagulation (e.g., Aspirin, ibuprofen) have an increased risk of bruising and bleeding. Rarely, a significant bruise such as a hematoma, or collection of blood outside of a blood vessel, may form. Hematomas may take up to a month or more to resolve. Treatments around the eyes commonly cause bruising.
Infection at the treated site with redness, swelling, pain, and possible abscess formation.
Although rare, needles or cannulas can lead to permanent scars at or around the injection sites
On rare occasions, red bumps, pustules (acne-like lesions), or a skin growth (keratoacanthoma) may form. Dr. Small must be notified if this occurs.
Discoloration of the skin such as grayish, bluish, or reddish coloration. Grayish/bluish discoloration more commonly occurs in thin skinned areas such as under the eyes and is known as the Tyndall effect.
Failure to reduce (under correction) or overcorrection of a contour defect, wrinkle, depression, or lips. Poor cosmetic result. Placement of filler adjacent to or outside of the desired treatment area. Undesired changes in facial contour; undesired formation of new folds or depressions.
Filler material may be extruded from the skin in rare cases.
Firm or hard areas in the injected area which may be detectable by feel. Visible raised areas or lumpiness at/around the treated site. These may persist from a few weeks to several months, and rarely may be permanent.
Rarely granulomas may form which are firm nodules. Granulomatous nodules are usually temporary but may be permanent.
Allergic reaction with itchiness, redness, and in extremely rare cases generalized allergic response such as whole-body swelling, respiratory problems, shock, and the remote possibility of death with these severe allergic reactions.
Asymmetry, where the correction on one side may be different from the correction on the other side of the face and undesired disfiguring facial changes including but not limited to: excessive lip curvature and protrusion, worsening eye bags, contour irregularities in areas adjacent to treated areas. This may include unequal lips, folds, or lines. Swelling at the time of injection may create the appearance of asymmetry or overcorrection which usually resolves as described above. You may, however, need to return for additional treatment if asymmetry persists.
Fillers may have an unpredictable duration of action and may not last as long as anticipated (e.g., with rheumatologic disorders such as rheumatoid arthritis) or may persist in some areas longer than anticipated. No guarantees have been made to me regarding the duration of action of the filler treatment that I am receiving.
A remote and rare risk is that of injecting filler into a blood vessel (blood vessel occlusion) or overfilling the tissue which can block blood flow (ischemia) to the treated area or to distant areas causing tissue damage and tissue death (necrosis) resulting in skin breakdown, scab formation and/or scarring, depression, or unevenness in or near the treated area. The risk of ischemia is greater in patients who have undergone facial plastic surgery. Blood vessel occlusion can result in blindness if filler is injected in a blood vessel near the eye such as in the tear trough or in the frown area. Blood vessel occlusion can result in necrosis of the side of the nose or cheek if filler is injected into a blood vessel near the nose or nasolabial fold. Plastic surgery with skin grafting may be required to treat a complication such as this.
Financial responsibilities. Additional costs may be incurred should complications develop from your treatment including but not limited to: surgery (such as, skin grafting), hospital charges, laboratory, radiology or other follow-up tests or treatments. I understand that I am solely responsible for any additional costs incurred.
All the risks of fillers may not be known. RSMD Medical Spa is not responsible for any filler risk or unforeseen complication not yet discovered or not commonly known.

I consent to administration of any related treatments that may be deemed necessary or advisable in association with or as a result of my procedure. This includes, but is not limited to: hyaluronidase, local anesthetic such as anesthetic injections with lidocaine 1% -2% with or without epinephrine; and/or topical anesthetics such as /lidocaine/tetracaine cream or ointment; and/or topical oral benzocaine preparations. The risks, side-effects, complications of these anesthetics include, but are not limited to: skin irritation (itching or redness), lightheadedness, rapid heart rate, visual disturbance, tongue numbness, and seizure. I will inform the physician or nurse immediately if I experience any of these symptoms. I do not have an allergy to lidocaine or anesthetics. I understand that dermal filler treatment refers to filler injections and any related treatments.

No guarantees can be made or have been made that I will benefit from treatment or achieve a desired level of correction. There is no guarantee that wrinkles and folds will be reduced. I understand that I may require additional Filler to achieve correction and that I am responsible for the cost of any additional Filler.

I understand that the fees for dermal filler treatments are not covered by insurance. Should additional filler be required, I am responsible for the cost of that additional treatment. RSMD Medical Spa will not bill my insurance. I understand that my insurance may not cover treatment of any complications should they arise, and that I am responsible for the cost of any additional treatment that may arise from any complications. I am responsible for paying the quoted fee for every treatment.

I consent to be photographed. Photographs shall be part of the medical record and may be used for educational purposes and marketing.

I have fully disclosed all of my medical history. I understand that it is my responsibility to inform and update RSMD Medical Spa's physician or nurse of any change in my health status and medical history at each visit and that failure to do so may increase the likelihood or severity of complications. All information provided to RSMD Medical Spa is, to the best of my knowledge, true and correct.

I am an adult of at least 18 years of age. My signature below certifies that I have fully read this consent form and understand the information provided to me regarding the proposed procedure. I have been adequately informed about the procedure including: the potential benefits, limitations, alternative treatments. I have had enough time to consider the information and I have had all questions and concerns answered to my satisfaction. I understand and accept the risks, side-effects and possible complications associated with filler treatment.

I hereby waive, release, discharge any and all claims and agree to indemnify, defend and hold harmless Dr. Small, the medical staff, specific technician, and RSMD Medical Spa, its members, employees, and affiliates for any injury, loss, expenses, or damages of any nature which may arise or be alleged as a result of my treatments, including that caused solely or in part by the fault of the above-named parties.

I consent and authorize Dr. Rebecca Small, a physician assistant, or Registered Nurse of RSMD Medical Spa to perform dermal filler treatments. This consent shall apply to all subsequent dermal filler treatments.

If I have any questions or problems after treatments, I will contact RSMD Medical Spa directly at (831) 475-1077.

By signing below, I certify that I have fully read and agree to adhere to the pre-treatment and post-treatment instructions. I understand that failure to carefully follow these instructions may affect my treatment outcome and increase the likelihood or severity of complications. Any applicable paragraphs were stricken before I signed. I also state that I speak, read, and write English.

Dermal Filler Pre & Post Treatment Instructions

Dermal fillers include: hyaluronic acid (Restylane, Hylaform, Hylaform Plus, Captique, Juvederm); calcium hydroxylapatite (Radiesse, Radiance); collagen (CosmoDerm, CosmoPlast).

Prior to Treatment

Avoid aspirin (e.g., Excedrin), vitamin E, St. John’s Wort and other dietary supplements including: ginkgo, evening primrose oil, garlic, feverfew, ginseng, bilberry, cayenne, dong quai, fish oil, ginger, and licorice root for 2 weeks.
Avoid ibuprofen (Advil, Motrin), naproxen (Aleve) and other anti-inflammatory medications for 1 week.
Avoid alcohol consumption for 2 days.
The treatment area must be free of any open sores, lesions, or skin infections (e.g., active acne), or treatment may need to be rescheduled.
Increase consumption of green leafy vegetables (such as kale or spinach) for 2 days.
If you have a history of herpes (cold sores) in the treatment area, start your anti-viral medication (valacyclovir, acyclovir) at the dose recommended by the provider 2 days prior to treatment and continue for 3 days after treatment.
Medications that may help support healing and reduce bruising and swelling are: Arnica Montana (cream and oral supplements), bromelain, and vitamin C. They can be purchased at health food stores like Whole Foods, Staff of Life and New Leaf. These may also be used after treatment.

After Treatment

Avoid touching the treated areas for 6 hours following treatment. After that, gently wash twice daily with mild soap. Avoid irritants such as glycolic and Retin-A products, toners, exfoliants, astringents, hot water or other products that cause irritation. You may resume use of your regular products 1 week after treatment, if there is no evidence of skin irritation.
Do not massage the treated areas and avoid activities that can cause flushing for 24 hours after treatment or as instructed by provider including: consuming alcohol, exercising, extensive sun or heat exposure, using hot tub or sauna.
Skin redness and swelling in the treatment area is common. This should resolve within a few days. If it persists longer than 3 days, please contact RSMD Medical Spa.
Gently apply a cool compress or wrapped ice pack to the treated areas for 15 minutes every few hours as needed to reduce discomfort, swelling, or bruising up to a few days after treatment. If bruising has occurred, it typically resolves within 7-10 days. If bruising is severe, please call our office. In some cases, we will speed up bruise resolution by treating with a laser (please note: we do not treat all bruises with a laser).
Mineral make-up can be worn immediately after treatment provided there is no skin irritation or problem.
Take Tylenol (acetaminophen) as needed for discomfort, avoid aspirin and anti-inflammatory medications (ibuprofen, Advil, Motrin) for 48 hours.
RSMD Medical Spa offers a follow-up visit 2 weeks after filler treatment. If additional product is needed, there will be an associated fee. Please contact our office to make a follow-up appointment.

Please contact RSMD Medical Aesthetics at (831) 475-1077 if you have any questions. If problems arise after hours, please contact your nearest urgent care facility.