Dermal Filler Treatment Consent

# Dermal Filler Treatment Consent **Practice / Clinic:** ___________ **Provider:** ___________ **Date of Service:** ___________ --- ## Patient Information Patient Name: ___________ Date of Birth: ___________ --- ## Nature of the Procedure Dermal fillers are injectable substances used to restore volume, soften lines and folds, augment facial features, and improve facial contour. The most commonly used fillers contain hyaluronic acid (HA), a naturally occurring polysaccharide, in cross-linked gel form. Examples include Juvederm®, Restylane®, Sculptra®, and Radiesse®. Non-HA fillers (calcium hydroxylapatite, poly-L-lactic acid) may also be used. HA fillers can be partially or fully dissolved with hyaluronidase if needed. **Treatment area(s) requested:** ___________ **Product(s) to be used:** ___________ Common treatment areas include lips, nasolabial folds, marionette lines, cheeks/midface, chin, jawline, tear troughs, temples, and hand rejuvenation. --- ## Expected Benefits Filler injections can restore youthful volume, improve facial symmetry, soften deep lines and folds, augment lips and cheeks, and project the chin or jaw. Results are typically visible immediately (with some initial swelling) and last 6–24 months depending on the product used, area treated, and individual metabolism. Lips and areas with high movement metabolize filler faster. --- ## Material Risks and Side Effects