This form is not just a formality- it’s a record of your decision to consent to a procedure having considered the risk of both positive and negative outcomes and medical risks listed below, and the impact they may have on your well-being.
The purpose of this form is to provide written information regarding the risks, benefits and alternatives of the administration of DERMAL FILLERS (Juvederm, Restylane, Revanesse, etc). Dermal fillers are used in the correction of moderate to …
You have been given a copy of this consent form. Your consent and authorization for this procedure is strictly voluntary. By signing this informed consent form, you hereby grant authority to your healthcare practitioner to perform facial augmentation and filler therapy injections using dermal fillers and/or to
consent form. THE TREATMENT Treatment with dermal fillers (such as Juvederm, Restylane, Radiesse and others) can smooth out facial folds and wrinkles, add volume to the lips, and contour facial features that have lost their volume and fullness due to aging, sun
Please print and bring this form with you to be completed at your appointment. JUVÉDERM ® ULTRA XC injectable gel is indicated for injection into the mid-to-deep dermis for correction of moderate to severe facial wrinkles and folds (such as nasolabial folds)
understand this is an elective procedure and I hereby voluntarily consent to treatment with dermal fillers for facial rejuvenation, lip enhancement, establish proper lip and smile lines, and replacing facial volume. The procedure has been fully explained to me.
prior to signing the consent form. THE TREATMENT Treatment with dermal fillers (such as Juvederm, Restylane, Radiesse and others) can smooth out facial folds and wrinkles, add volume to the lips, and contour facial features that have lost their volume and fullness due to aging,