DERMAL FILLERS
The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure named above. This material serves as a supplement to the discussion you have with your doctor/healthcare provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form.

ABOUT DERMAL FILLERS
A Dermal Filler is an injectable gel that is placed by varying depths, under the skin by an Injection Specialist. Once injected, it integrates into the skin to smooth lines and wrinkles. Individual fillers work to volumize, plump and fill moderate to severe facial wrinkles and folds.

REVANESSE VERSA: Versa is a high viscosity sterile smooth gel filler made of hyaluronic acid. The spherical particle shapes a reoptimized to provide smoothness and volume. Versa is FDA approved for mid dermis implantation to volumize and correct moderate to severe lines, folds and lip enhancement. Versa may last up to one year. Individual results may vary. Optimal results and longevity will depend largely upon the amount of any filler/neuromotor injected and the severity of the area to be corrected.

The Treatment with dermal fillers 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 exposure, illness, etc. Facial rejuvenation can be carried out with minimal complications. These dermal fillers are injected under the skin with a very fine needle. This produces natural appearing volume under wrinkles and folds which are lifted up and smoothed out. The results can often be seen immediately.

RISKS AND COMPLICATIONS
Before undergoing this procedure, understanding the risks is essential.
Like any injection procedure, there are risks of infection, lumpiness, redness, bruising, swelling, itching, pain and/or tenderness at the injection site. Typically resolution is spontaneous within a week after injection. Patients who are using medication that can prolong bleeding, such as aspirin, warfarin or certain vitamins and supplements, may experience increased bruising or bleeding at the injection side and/or surrounding tissue. You must disclose all medications, vitamins, and supplements. Any foreign material injected into the body may create the possibility of swelling or other local reactions to filler material.

NODULES AND PALPABLE MATERIAL: There is a risk that small lumps may form under the skin due to the injectable filler collecting in one area. You may be able to feel the injectable filler in the area where the material has been injected.

MIGRATION: The injectable filler may move from the place where it was injected.

INFECTION: As with all invasive procedures, the implantation of a filler may cause an infection at the injection site.

ALLERGIC REACTIONS: Injectable fillers should not be used in people with severe allergies, a history of anaphylaxis or history or presence of multiple severe allergies or hypersensitivity to any injectable filler.

HYPERSENSITIVITY: Consists of EXCESSIVE swelling, bruising, and firmness sometimes affecting the surrounding tissues that may include redness, tenderness, and in some rare instances, acne-like formations. If hypersensitivity occurs, the average duration usually resolves in about two weeks.
FEVER BLISTERS/COLD SORES: If you have a history of fever blisters/cold sores, there is a risk that the needle punctures could activate a breakout. Disclosure of previous outbreaks is mandatory before injection. Medications may be prescribed prior to injection to minimize or prevent a recurrence.

RADIO-OPACITY: Injectable filler is radiopaque and is visible on CT scans and may be visible on x-rays.

ACCIDENTAL INJECTION INTO A BLOOD VESSEL: Injectable filler can be accidentally injected into a blood vessel, which may block the blood vessel and cause local tissue damage or potentially a heart attack or stroke.

DURATION OF EFFECT: The outcome of treatment with injectable filler will vary among patients. In some instances, the additional filler may be necessary to achieve the desired outcome. It may be necessary to return for additional filler. The desired outcome may not be an attainable goal. Full correction may not be possible and a soft improvement may be the extent of treatment in varying areas.

PREGNANCY: I am not aware that I am pregnant. I am not trying to get pregnant. I am not lactating (nursing). I do not have or have not had any major illnesses which would prohibit me from receiving dermal fillers. I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to lidocaine.
If possible, full correction to an area will increase the longevity of the filler. Touchup and follow-up treatments help sustain the desired degree of correction.

POST-TREATMENT INSTRUCTIONS:
You should avoid the following for at least 24 hours after treatment:
• Exposure to extreme heat such as sun, tanning beds, Jacuzzis or saunas. Strenuous exercise.
• Alcohol consumption.
• Vigorous contact with the treated area for 6 hours. After that, the areas may be gently washed with soap and water.
• Exposure to any of the above may cause temporary redness, swelling and/or itching at the injection sites.
• Swelling and redness will usually resolve within 3-4 days.
• Softening of the filler and integration into the tissue will usually occur within 2-4 weeks.
• Aspirin, Ibuprofen, Motrin, Advil, Aleve, St. John’s Wort, high doses of Vitamin C and Fish Oil. These agents may increase bruising and bleeding at the injection site. DO NOT DISCONTINUE USE OF ASPIRIN OR WARFARIN IF PRESCRIBED BY YOUR PHYSICIAN.

You may apply cold compresses and use medication as directed to help decrease swelling and bruising. You will be asked to avoid massage, chemical peels, facials and laser treatments up to 2 -4 weeks post-treatment. Discuss any scheduled facial surgery or dental procedures prior to injection.

This information is not meant to be inclusive of all possible risks associated with injectable fillers, as there are both known and unknown side effects and complications associated with any medication or dermal filler injection procedure. I understand that medical attention may be required to resolve complications associated with my injection. I have discussed the potential risks and benefits of injectable fillers with my Injection Specialist. I understand that there is no guarantee of any particular results of any treatment. I understand and agree that all services rendered will be charged directly to me, and I am personally responsible for payment. By signing below, I acknowledge that I have read the foregoing informed consent, have had the opportunity to discuss any questions that I have with my Injection Specialist to my satisfaction, and consent to the treatment described above with its associated risks.

I have read, and acknowledge these requirements of the procedure. 

Medical Waiver

I have read, and acknowledge these requirements, of my procedure to better assist with treatment adversities that can occur if a protocol is not taken seriously. I know that this is an elective service and my questions regarding services have been answered satisfactorily I understand this procedure and accept all risks and will notify Top Beauty Bar of any changes that could put my treatment at risk.

I take full liability and responsibility for all risks, undesired outcomes, or adverse events associated with the injections and will not hold the provider of Top Beauty Bar LLC liable for any unfavorable outcome or adverse event. I release Top Beauty Bar LLC, its owner, and medical staff from liability associated with the procedure. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns. I hereby release Top Beauty Bar LLC, Tina Videtic, and staff from all liabilities associated with the indicated procedure. The procedures to be used to treat my condition have been explained to me. Any adverse reaction should be reported immediately to the office mobile at 920-678-7709.

I have read, and acknowledge these liability requirements of my procedure.