BODY FILLER INJECTION CONSENT FORM

Patient�s Name:
File No.:
DOB:
Mobile Number:
Visit Date:
Registration Time:
Doctor Name:

Instructions.

PRE-INSTRUCTIONS:

- Patients with blood diseases are contradicted to undergo FILLER injection.
- Patients must stop the following 3 days prior to the procedure:
- Aspirin, brufen, sabofen, multivitamins, vit. e & green tea

SIDE EFFECTS:
- Pain or burning sensation
- Minimal swelling for 1 to 2 days
- Possible bruise for 2 to 14 days
- Redness at the injection area for up to 5 days
- Diabetic patient may experience delayed wound healing on the punctured sites
- Risk for infections due to multiple punctured sites so fucidin and bactroban ointment or cream must be applied 3x a day for 5 to 10 days post FILLER injection.
- There is no risk of allergic reaction but may develop allergy due to local anesthesia.
- Visible result will not be immediate

POST INSTRUCTION:
- Do not let down on the back for 5 days
- Wear the pressure garment for 2 weeks
- Keep the taping support for 5 days, if it gets wet, it needs to be replaced again immediately
- Increase the water intake for better results, up to 2 to 3 liters of water per day
- Antibiotic treatment for 5 days
- Simple analgesics for pain

I certified that I have read and understand the contents of this form and do realize the side effects and limitations involved. I hereby authorized my doctor to perform FILLER injection and relieve my Doctor of the responsibility of any complications.

I understand and agree that I am financially responsible for the payment I made for that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months period. I agree that my payment made is non-refundable or non-transferable post this period.

I declare that I have read and fully understood all points in this consent and that all of my questions were answered to my satisfaction and I take the full responsibility of my decision in this consent.

 

Patient Name & Signature :   

Doctor/Therapist Name & Signature :   

Witness Name & Signature :     

Parent or Gaurdian Name (if patient is minor) :

Date :

Consent to be photographed and published

I, , consent to be photographed and published on Social media, by while before and after the procedure. I further authorize that the photographs may be published for any purpose and in any form.

Patient Name & Signature :