Self Assessment
Choose Consent Form
abdominoplasty surgery
File Number:
Consent Form - Fillers
Terms and Conditions:
The most common side effects include temporary injection site reactions such as redness, pain/tenderness, firmness, swelling, lumps/bumps, bruising, itching, and discoloration.
Other rare risks include, but are not limited to:
a) Overcorrection / under correction & facial asymmetry
b) Unpredictable persistence of filler, either shorter or longer than expected.
c) Prolonged discolouration of the skin
d) Prolonged or severe swelling
e) Reactivation of coldsores
f) Infection
g) Scarring
h) Ulceration
i) Granulomas or firm nodules
j) Benign tumour formation (keratoacanthomas)
k) Allergic or anaphylactic reaction
l) Blindness
m) A remote and extremely rare risk is that of filler injection into a blood vessel, leading to blockage of the vessel. This could result in reduced blood flow to an area of tissue, leading to tissue damage and tissue death (necrosis), which could be seen as skin breakdown, ulceration and scar formation. Blood vessel blockage near the eye can result in blindness.
• You should see an immediate improvement in the treated areas on the day. Depending on the area treated results may last 6 months or more.
• Dermal Fillers should not be used in patients who have severe allergies marked by a history of anaphylaxis, a history of severe allergies, or patients with a history of a compromised immune system. The doctor will ask you about your medical history to determine if you are an appropriate candidate for treatment.
• Alternatives to the procedures and options that I have volunteered for have been fully explained to me
• Client experiences may vary.
• Any contraindications will void this treatment
• This treatment cannot be transferred to another person
• Once the injection has been given, refunds are prohibited
• Appointments preferences are based on availability
• I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:
• Pre and post treatment instructions have been explained to me
• I have had sufficient time to consider the Cellfina® treatment and had the opportunity to ask questions, and all of my questions have been answered to my satisfaction and understanding
• Must notify the clinician if my medical history changes prior to subsequent treatments
I consent to clinical photographs being taken of my treated areas for my personal health record only
• My signature below constitutes my acknowledgment and understanding of all this information
Patient Name
Patient Signature
Date /Time
Parent or Guardian (if patient is minor)
Witness
Patient Signature
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