Celebrity Cosmetic Dermatologist

Consent Form for Aesthetic Filler Treatment

Prime HealthAddress: 1035 Sterling Rd, Suite 104, Herndon, VA 20170

Physician Name: Dr. Han Tonthat

1. Purpose of this Consent

By signing this Consent Form, I acknowledge that I have been fully informed about the aesthetic filler treatment, including the procedure, expected outcomes, potential side effects, and risks. I voluntarily agree to proceed with the treatment, understanding its nature and scope.

2. Description of the Procedure

The aesthetic filler treatment involves injecting FDA-approved dermal fillers to enhance facial volume, reduce wrinkles, and improve overall appearance. The treatment areas may include, but are not limited to:

• Lips, cheeks, nasolabial folds, under-eye hollows, jawline, and chin.

The procedure is non-surgical, and results are temporary, lasting between 6 months to 2 years, depending on the product used, the treatment area, and individual factors.

3. Expected Results

The procedure aims to:

1. Improve facial aesthetics by smoothing wrinkles or enhancing contours.

2. Provide temporary improvement, requiring follow-up treatments for maintenance.

I understand that results are subjective and may vary based on individual anatomy, body chemistry, and adherence to post-treatment care instructions.

4. Potential Risks and Side Effects

I understand that all medical procedures carry risks, and while dermal fillers are generally safe, side effects and complications may occur. By signing this document, I acknowledge that I have been informed of the following:

Common Side Effects (Temporary and Mild)

These are typical and usually resolve within a few hours to a week:

1. Redness: Around the injection site.

2. Swelling: Mild to moderate, depending on the area treated.

3. Bruising: Especially in areas with thin skin, such as the lips or under the eyes.

4. Tenderness or Pain: Common near the injection site.

5. Itching: Temporary, particularly in sensitive skin areas.

6. Lumps or Bumps: Small irregularities under the skin; often settle naturally or with gentle massage.

Less Common Side Effects

These occur less frequently and may require additional care:

1. Asymmetry: Uneven results requiring touch-ups.

2. Overcorrection: Too much filler causing an unnatural or “overfilled” look.

3. Under-Correction: Insufficient filler leading to incomplete results.

4. Prolonged Swelling: Persisting for several weeks in rare cases.

5. Delayed-Onset Swelling: May occur weeks after treatment due to immune responses.

Rare but Serious Side Effects

These complications are uncommon and may require immediate medical intervention:

1. Infection:

   • Bacterial, fungal, or viral infection at the injection site.

   • Symptoms: Redness, warmth, pain, or discharge.

2. Allergic Reactions:

   • Rash, itching, or swelling beyond the treatment area.

   • Severe cases can result in anaphylaxis (life-threatening).

3. Tissue Damage or Necrosis:

   • If the filler blocks blood flow, it can cause tissue death.

   • Symptoms: Intense pain, discoloration, or ulceration.

4. Vascular Occlusion:

   • Filler enters or compresses a blood vessel, blocking circulation.

   • Symptoms: Blanching, severe pain, or skin turning dark or cold.

5. Scarring:

   • Rare but may occur if healing is impaired.

6. Granulomas:

   • Hard, inflammatory lumps forming around the filler material.

   • May require corticosteroid injections or surgical removal.

Extremely Rare and Critical Side Effects

1. Vision Problems or Blindness:

   • If filler is accidentally injected into or near an artery supplying the eye.

   • Symptoms: Sudden vision changes, severe pain, or swelling.

   • Requires immediate emergency care.

2. Stroke:

   • Filler entering the bloodstream and blocking vessels in critical areas.

   • Symptoms: Numbness, slurred speech, weakness.

3. Migration of Filler:

   • Filler moves from the injection site to unintended areas, altering appearance or causing discomfort.

Long-Term Risks

1. Chronic Swelling or Puffiness:

   • Persistent in some individuals, especially in areas like under the eyes.

2. Changes in Skin Texture:

   • Thinning or thickening of skin over time in treated areas.

3. Uneven Breakdown of Filler:

   • Filler may not dissolve evenly, leading to lumps or irregularities.

Specific Risks by Treatment Area

Lips:

• Swelling is more common and can be pronounced.

• Risk of “duck lips” or an unnatural appearance.

Under Eyes:

• Puffiness or a “blue tint” (Tyndall effect) if filler is placed too superficially.

Nose (Non-Surgical Rhinoplasty):

• Increased risk of vascular occlusion due to dense blood vessel networks.

Psychological Effects

1. Dissatisfaction:

   • Results may not meet expectations, especially if expectations are unrealistic.

2. Body Dysmorphia:

   • Rare psychological condition where patients obsess over perceived flaws.

5. Patient Responsibilities

To ensure the best possible outcomes and minimize risks, I agree to:

1. Provide Accurate Medical History: Disclose all current medications, allergies, and medical conditions.

2. Follow Pre- and Post-Treatment Instructions:

   • Avoid alcohol, smoking, and blood-thinning medications for 24–48 hours before and after treatment.

   • Refrain from strenuous activities or excessive sun exposure immediately after the procedure.

3. Notify the Clinic: Report any unusual side effects or concerns immediately.

6. No Guarantee of Results

I understand that aesthetic outcomes are subjective and may vary. I acknowledge that while the procedure is performed with care, there is no guarantee of achieving specific results, and additional treatments may be required to meet my expectations.

7. Refund Policy

The Patient acknowledges and agrees to the following refund terms:

1. Non-Refundable Services: All fees for completed services are non-refundable.

2. Health-Related Refunds: If treatments are stopped due to verified health issues, refunds will be issued only for unused treatments.

3. Payment Obligations: If enrolled in a payment plan, the Patient must complete all payments, even if they discontinue the program.

8. Emergency Contact

9. Acknowledgment and Consent

By signing below, I confirm that:

1. I have read and understood this Consent Form and its contents.

2. I have been informed of the procedure, risks, and benefits, and had all my questions answered.

3. I understand the risks, including rare but serious complications, and agree to proceed with the treatment.

4. I release Prime Health, its staff, and practitioners from liability for any complications, except those caused by gross negligence or malpractice.

Patient Compliance and Limitation of Liability Disclaimer (Commonwealth of Virginia)

I understand and acknowledge that the administration of dermal fillers is an elective medical procedure, and that individual results may vary based on numerous factors, including but not limited to my unique physiology, medical history, and adherence to medical instructions. I further acknowledge that I have been provided with pre- and post-procedure care instructions and that it is my responsibility to comply fully with these instructions and to attend all recommended follow-up appointments.

I understand that failure to follow such instructions or attend follow-up care may adversely affect the outcome of the procedure and may increase the risk of complications. Accordingly, I hereby release and hold harmless [Clinic Name], its providers, and employees from any and all liability, claims, or damages arising from unsatisfactory results or complications related to non-compliance with medical advice.

I further understand that no guarantees, warranties, or assurances have been made to me regarding the results of this treatment, and I voluntarily accept the risks associated with this procedure under the laws of the Commonwealth of Virginia.