SOFT TISSUE FILLER 2012 CONSENT FORM

I, __(Your name) __________________________

Hereby consent to the procedure of SOFT TISSUE FILLER treatment to be carried out on myself.

FILLER TYPE: JU / JUP / JU Re / R / P / ES / Fort/ Fort ex/ Mod / RA / Re V

LOCATION:

ANAESTHETIC CHOICE: TOPICAL / ICE / DENTAL BLOCK / LOCAL INFILTRATION

I have been informed regarding the treatment and procedure, indications, expected results and possible side effects.

I am aware of bruising, of which almost always occurs, and that I may need to take TIME OFF work depending on the areas treated. 

I am not aware of any contra-indications that may prevent this treatment:

- Pregnancy, breast-feeding, previous allergic reaction to fillers,

- PRIOR TREATMENT WITH OTHER TYPES OF DERMAL FILLER

I had the opportunity to discuss all questions answered to my satisfaction.

I have been given and read the post treatment care plan information sheet.                               

I have been given and read the disclaimer and refund policy.

I agree that this procedure is being carried out for cosmetic reasons and no guarantee of any nature can be made as the result of the procedure. 

I accept that while every precaution will be taken to prevent complications and that while complications from the procedure are rare, they can and sometimes do occur.

I am undergoing this treatment of my own free will. 

I accept responsibility for any complications and thereby absolve anti-aging, Dr Louisa Yim and other associated persons of any blame resulting there from.

I understand that photographs might be taken before, during and after the treatment.  The sole purpose is to demonstrate and compare the differences prior to and after treatment. 

Should these be used in publication, my permission will be obtained and my identity is protected.

CLIENT SIGNATURE:  ________________________

DATE:

Doctor SIGNATURE:  ________________________

DATE: