DERMAL FILLER CONSENT FORM

NAME: _____________________________________________

Date of birth: _________________________________________

Address: _____________________________________________

Contact tel: ___________________________________________

Allergies: _____________________________________________

Medication: ____________________________________________

I, (your name) ________________________________________________

Have discussed the risks, benefits, and the cost of Dermal filler treatment with Dr Louisa Yim.

I give consent to have the choice of anaesthetic:

I give consent to have the following areas treated:

*

*

*

*

With the product/(s):

* Juvederm Ultra * Juvederm Ultra plus * Restylane * Restylane Lipp * Restylane Vital

I am aware of potential side effects, and that I may need to take TIME OFF work depending on the areas treated. Some of the potential side effects discussed are:

- Redness, itchiness, inflammation, post inflammatory pigmentation (rare), bleeding, bruising +++, asymmetry, allergic reaction (rare)

I have discussed all the medications/herbal supplements that I am taking.

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 EG JUVEDERM, SCULPTRA, RADIASSE, SILICON, RESTYLANE

(IT IS NOT ADVISABLE TO MIX FILLERS DUE TO THEIR DIFFERENCES IN HYLAURONIC ACID STRUCTURE)

I understand the post treatment care plan and will follow the instructions as directed.

I have read the above information and I am happy to proceed.

Signed: Date: ________/________/_______