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HA FILLER CONSENT FORM

I hereby consent to hyaluronic acid filler treatment. I understand that a liquid made of hyaluronic acid will be injected into areas of my face to smooth out folds and wrinkles resulting in a healthy vital appearance. Liquid Hyaluronic acid is also used for lip and body enhancement if I so desire.

Good results may be obtained after a single session and the effects will be immediately visible and last for several months depending on the filler used.
The treatment session lasts about 30 minutes and depending on the area to be treated, a local anesthetic or anesthetizing cream may be applied.
There may be mild discomfort while having the injections and the swelling will subside after 24-48 hours.
Side effects of this treatment are rare, in such cases prolonged redness and tenderness at the injection site can be experienced but will subside after a few days or weeks, beading under the skin (granulomas) may occur in occasional cases, and very rarely infection or allergic reaction may happen.
It is advisable not to put any cream or make-up on the treated area for 1-2 days at least.
The aim of the filler is to improve create volume to requested areas of the skin. I fully understand that the degree of benefit will depend on my individual response to this treatment.
I also have informed that it is very important to tell the doctor who will perform this treatment, about any disease or drugs I am suffering from or taking which may increase sensitivity to this treatment and may cause complications (like herpes simplex, etc..).

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 the opportunity to ask questions, and all my questions have been answered to my satisfaction.
I declare that while completing the medical questionnaire, I have answered the information related to my personal medical history questions completely and I have not withheld any information.
I 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.
There are no refunds for services rendered and/or after a year from purchase and not used.
The treatments I receive here are voluntary and I release KAI LIFE CLINIC, my doctors, nurse and/or my technician from liability and assume full responsibility thereof for this appointment and future appointments.
My signature below constitutes my acknowledgment and understanding of all this information.

I hereby authorize and direct the doctors and/or technician to perform the treatment on me.

Patient Name

Patient Signature

Date/Time

Doctor Name

Signature

Date

Witness Name

Witness Signature