DERMAL FILLER INJECTABLE CONSENT FORM

You have a right to be fully informed about your treatment, its purpose, and potential risks. This document is not intended to alarm you but to ensure that you understand the procedure and can make an informed decision about whether to proceed.

CLIENT INFORMATION AND CONSENT

I, (insert full name), acknowledge and consent to receiving dermal filler injections for contouring, volumising, and correcting facial wrinkles, folds, and lips. The treatment involves injecting hyaluronic acid gel intradermally through a fine gauge needle into the specified areas.

I understand the following details about the procedure:

  • Dermal fillers are used to improve facial contour and correct deeper folds and wrinkles.
  • Multiple syringes or treatments may be necessary to achieve the desired results.
  • Results typically last up to 9 months or longer but can vary based on individual factors and the area injected.
  • Touch-up treatments may be required to maintain the desired outcome.
  • Clinical results may vary between patients.
POSSIBLE SIDE EFFECTS

I acknowledge that potential side effects of the procedure include, but are not limited to:

  • Allergic reactions or infections
  • Bleeding at the injection site
  • Tenderness, pain, or discomfort
  • Redness or swelling at the injection site
  • Bruising or scarring
  • Lumps, bumps, or uneven texture
  • Recurrence of cold sores in clients with a history of herpes simplex virus

Note: Clients prone to cold sores should inform the clinic and may benefit from antiviral medication before treatment.

SUITABILITY FOR THE PROCEDURE

I understand the following contraindications for this treatment:

  • Clients who are pregnant, may be pregnant, or are breastfeeding are not suitable for this procedure.
  • Individuals with known allergies to bacterial proteins or specific components of dermal fillers may not be eligible.
  • It is my responsibility to inform the clinic of any history of allergic reactions or relevant medical conditions.
POST-TREATMENT INSTRUCTIONS

I agree to follow all post-treatment instructions provided by Mojo Cosmetic Clinic to minimise the risk of complications, ensure proper healing, and optimise the results of the treatment.

ACKNOWLEDGMENT AND CONSENT

I confirm that:

  • The nature, purpose, and risks of the procedure have been explained to me in detail.
  • All my questions have been answered to my satisfaction.
  • I understand the potential risks and side effects associated with this procedure.
  • I have been informed of alternative treatments, their risks and benefits, and my right to refuse treatment.
  • I am at least 18 years of age and am competent to provide consent.
  • I release Mojo Cosmetic Clinic and its staff from liability associated with this procedure.
Draw your signature using your fingers or mouse in the box below

Please click on the Tick icon() to verify your signature. After that you can submit the form.