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MIRAGE Salon & MedSpa
Informed Patient Consent for Treatment with Injectable Fillers
I certify that I am a competent adult of at least 18 years of age
I certify that I am a minor under the age of 18 and understand that the consent of my parent/legal guardian will also be required before treatment.
I understand the fillers to be used include Hylaform, Restylane, Collagen and/or Juvederm.
I certify that the nature and purpose of the treatment has been explained to me and questions I have regarding the treatment have been answered to my satisfaction.
I am fully aware of the risks of complications or injuries that can occur from this treatment, both from known and unknown causes, and I freely assume those risks.
Known complications could include, but are not limited to:
Redness, swelling/edema, itching, pain or pressure lasting more than one week.
Nodules or induration at the injection site.
Discoloration of the injection site.
Poor effect or week filling.
Allergic reactions.
I also certify that I have none of the known conditions that would contraindicate treatment. These conditions include hypertrophy scars, a history of any autoimmune disease, or immune therapy. I am not pregnant, breast-feeding, and I have no known allergy to hyaluronic acid or bovine source collagen.
I understand this informed consent is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns.
I agree that any picture taken of my treatment site may be used for publication and teaching purposes, however, my name will not be disclosed and complete confidentiality of my name will be maintained.
I understand that no guarantee, warranty or assurance has been made as to the treatment results.
I understand that the results are of temporary nature, and more treatments will be needed to maintain improvement.
I agree to adhere to all safety precautions described, including those below:
Avoiding prolonged sun or UV exposure
Avoiding saunas for two weeks after injection
Avoiding steam baths for two weeks after injection
Make up should be avoided for at least 12 hours after injection.
I certify that I have read this entire informed consent and that I understand and agree to the information stated in this form.
I consent to allowing Mirage Salon & MedSpa permission to use the photographs on their social media for promotional purposes.