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Forms

MIRAGE Salon & MedSpa

Fillers Informed Patient Consent Form

Informed Patient Consent for Treatment with Injectable Fillers

Patient Information

SECTION 1: ACKNOWLEDGMENTS AND AGREEMENTS

I, the above mentioned Patient, consent to, and authorize the following selected Provider to perform with injectable fillers to improve the appearance of scars and/or wrinkles, or to have my lips augmented (made larger).
Jami Maxey
Kelly Jueden
Cari Paden
Miranda Lockman
Sonia Chicas
Other

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.

SECTION 2: CONSENT

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