Informed Consent for Radiesse® (Calcium Hydroxylapatite) Dermal Filler & Biostimulatory Injections

This consent form confirms that I have been fully informed and educated regarding Radiesse® (calcium hydroxylapatite) injections, including their use as a volumizing dermal filler and as a biostimulatory treatment (including hyperdilute Radiesse) for collagen and elastin stimulation. I have also been informed of potential benefits, alternatives, limitations, risks, and possible complications, and I have received pre- and post-treatment instructions. This information allows me to make an informed and voluntary decision regarding treatment.

Treatment History

I acknowledge that I have informed my provider of any prior dermal filler or biostimulator injections, including product type, treatment dates, and treatment locations.

Nature of the Product & Procedure

• I understand that Radiesse® is composed of calcium hydroxylapatite microspheres suspended in an aqueous gel carrier.
• I understand that Radiesse® may be used as a volumizing dermal filler to restore structure and contour and/or in a hyperdilute form as a biostimulator to stimulate the body’s natural production of collagen and elastin, improving skin quality, firmness, and texture over time.
• I understand that when used as a biostimulator, Radiesse® does not primarily provide immediate volume and that results may develop gradually over weeks to months as collagen and elastin are produced.
• I understand that the procedure involves the use of a needle and/or cannula to inject Radiesse® into specific layers of the skin or subcutaneous tissue.

FDA-Approved & Off-Label Use

• I understand that Radiesse® is FDA-approved for the correction of moderate-to-severe facial wrinkles and folds and for hand augmentation.
• I understand that use in other anatomical areas and/or in hyperdilute form for collagen and elastin stimulation constitutes off-label use, which is legally permissible, commonly practiced, and considered within the accepted standard of medical care.

Expected Results, Longevity & Maintenance

• I understand that improvement may be visible after the first treatment; however, optimal results may require multiple syringes and/or multiple treatment sessions depending on my treatment goals.
• I understand that when used for volumization, Radiesse® results may last approximately 9–12 months, although individual response varies.
• I understand that when used as a biostimulatory (hyperdilute) treatment, results are gradual, depend on my body’s collagen response, and may require a series of treatments for optimal outcome.
• I understand that maintenance treatments may be required to sustain results over time.

No Guarantee of Results

• I understand that although good results are expected, medicine is not an exact science and no specific outcome or duration of effect can be guaranteed, either expressed or implied.
• I understand that I am paying for professional medical services, not for a guaranteed aesthetic result.

Alternatives & Voluntary Decision

• I understand that alternatives exist, including other dermal fillers, biostimulatory treatments, energy-based devices, surgical procedures, or no treatment, and that these alternatives have been discussed 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 or sensitivities to calcium hydroxylapatite or lidocaine.
• I deny that I am currently pregnant, attempting to become pregnant, or breastfeeding. I understand that the safety of Radiesse® during pregnancy and 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, but are not limited to:

• Discomfort or tenderness
• Bleeding or bruising, increased by alcohol or blood-thinning medications
• Swelling, typically peaking within the first few days and resolving over several weeks
• Infection (rare)
• Perioral pustules (rare)
• Scarring (rare)
• Allergic reactions
• Unknown or unforeseen side effects

I understand that temporary firmness, nodules, or lumping may occur and usually resolve as the product integrates into surrounding tissue.

Vascular Complications (Rare but Serious)

• I understand that there is a small but real risk that dermal fillers may enter a blood vessel, which in most cases results in bruising but in rare cases may cause vascular occlusion leading to skin injury or tissue loss.
• I understand that very rarely, estimated at approximately 0.01% or less than 1 in 100,000 syringes used, 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 (white, mottled, or dusky), visual changes, or signs of stroke such as difficulty speaking, facial droop, weakness, dizziness, or confusion.

Emergency Management Authorization

I understand that if vascular compromise or other serious complications are suspected, immediate intervention may be required, including attempts to reverse or manage the complication, 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 Radiesse® injections on me.
• I acknowledge that I have had the opportunity to inquire about the qualifications and experience of the provider performing my treatment and that I am satisfied.
• I affirm that my consent is voluntary, informed, and freely given.

Final Acknowledgment

I acknowledge that I have read and fully understand this consent form, that all disclosures have been explained to me, that I have had the opportunity to ask questions, and that this form supersedes any prior verbal or written disclosures. I freely consent to Radiesse® dermal filler and biostimulatory injections.