AI WELLNESS CENTER OF EXCELLENCE
INFORMED CONSENT FOR HYALURONIC ACID (HA) DERMAL FILLER INJECTIONS
This consent form confirms that I have been fully informed and educated regarding hyaluronic acid (HA) dermal filler injections, including their purpose, expected benefits, alternatives, limitations, risks, and possible complications. I have also received pre- and post-treatment instructions. This information allows me to make an informed and voluntary decision regarding treatment.
TREATMENT HISTORY
I will notify my provider if I have previously received dermal filler injections, including product type, date(s), amount(s), and treatment area(s).
NATURE OF THE PROCEDURE
I understand that dermal fillers made of stabilized hyaluronic acid are used to restore volume, improve facial contours, soften wrinkles, and efface undesired folds.
I understand that the procedure involves the use of a fine needle and/or cannula to inject hyaluronic acid into specific layers of the skin to volumize and contour targeted areas.
FDA-APPROVED & OFF-LABEL USE
I understand that certain facial areas are FDA-approved for hyaluronic acid dermal fillers, which may include cheeks, nasolabial folds, perioral wrinkles, oral commissures, marionette lines, and lips, depending on the specific product used.
I understand that injection into other anatomical areas constitutes off-label use, which is legally permissible, commonly practiced, and considered within the accepted standard of medical care.
EXPECTED RESULTS, FULL CORRECTION & LONGEVITY
I understand that improvement may be visible after the first treatment; however, optimal results often require achieving full correction, which may necessitate the use of the recommended number of syringes as determined by my provider.
I understand that when full correction is achieved, the longevity of hyaluronic acid dermal fillers may last approximately 12–18 months, depending on the product used, treatment area, individual metabolism, facial movement, and lifestyle factors.
I understand that if full correction is not achieved, results may be less noticeable, may not last as long, and may not fully meet aesthetic goals.
I acknowledge that choosing to use fewer syringes than recommended may result in reduced longevity and incomplete correction and does not constitute a complication, improper care, or failure of treatment.
I understand that additional syringes may be required either during the same session or at subsequent visits to achieve optimal correction.
DURATION & MAINTENANCE
I understand that hyaluronic acid dermal fillers are temporary. Once full correction is achieved, results may last up to 12–18 months, though individual response varies.
I understand that maintenance or touch-up treatments may be required periodically to sustain optimal aesthetic outcomes.
NO GUARANTEE OF RESULTS
I understand that although good results are expected, medicine is not an exact science, and no specific outcome or duration can be guaranteed, either expressed or implied.
I understand that I am paying for professional medical services, not for a guaranteed aesthetic result or guaranteed longevity.
ALTERNATIVES & VOLUNTARY DECISION
I understand that alternatives exist, including other injectable treatments, energy-based procedures, surgical options, or no treatment, and I have discussed these alternatives with my provider.
I confirm that I have had the opportunity to ask questions and perform independent research regarding this procedure.
MEDICAL DISCLOSURE & CONTRAINDICATIONS
I agree to fully disclose all medical conditions, allergies, and medications, including supplements.
To the best of my knowledge, I have no known allergies to hyaluronic acid, gram-positive bacterial proteins, or lidocaine.
I understand that if I am prone to cold sores or herpes-like outbreaks, dermal filler injections may trigger a flare, and I have informed my provider and requested prophylactic medication if appropriate.
I deny that I am currently pregnant, attempting to become pregnant, or breastfeeding. I understand that the safety of HA fillers during pregnancy or breastfeeding has not been established. If uncertain, I will request pregnancy testing prior to treatment.
RISKS & POSSIBLE COMPLICATIONS
I understand that all injectable procedures carry risk. Potential risks include discomfort or tenderness, bleeding or bruising, swelling, infection, perioral pustules, scarring, allergic reactions, and unknown or unforeseen side effects.
I understand that temporary lumping, firmness, or irregularity may occur and typically resolves as the filler integrates into surrounding tissue.
VASCULAR COMPLICATIONS (RARE BUT SERIOUS)
I understand that there is a small but real risk that dermal filler may enter a blood vessel. In most cases this results in bruising; however, in rare instances it may cause vascular occlusion leading to skin injury or tissue loss.
I understand that very rarely, filler injected into a blood vessel may result in vision impairment or permanent blindness, which may not be reversible.
I understand that in extremely rare cases, vascular occlusion may result in skin necrosis, permanent scarring, stroke, or permanent vision loss.
I agree to immediately notify my provider if I experience severe or unusual pain, skin color changes, visual changes, or signs of stroke.
EMERGENCY MANAGEMENT AUTHORIZATION
I understand that if vascular compromise or other serious complications are suspected, immediate intervention may be required, including dissolving the filler with hyaluronidase and/or other emergency measures, and I consent to such treatment.
POST-TREATMENT RESPONSIBILITY
I understand that patient responses vary and delayed reactions may occur. I agree to promptly notify AI Wellness Center of Excellence of any concerns or adverse effects and allow the clinic the opportunity to evaluate and participate in my care.
AUTHORIZATION & PROVIDER QUALIFICATIONS
I hereby authorize Dr. Gideon Kwok, D.O., and/or trained and qualified licensed medical providers acting within their scope of practice to perform hyaluronic acid dermal filler injections.
I acknowledge that I have had the opportunity to inquire about the qualifications and experience of the provider performing my treatment and am satisfied.
I affirm that my consent is voluntary, informed, and freely given.
FINAL ACKNOWLEDGMENT
I certify that I have read and fully understand this consent form, all disclosures have been explained to me, I have had the opportunity to ask questions, this form supersedes any prior verbal or written disclosures, and I freely consent to hyaluronic acid dermal filler injections.
