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Consent for Sclerotherapy of Varicose and Spider Veins
Contact Us
Menu
About Us
Premises Inspection Committee Report
Cosmetic Surgeons in the GTA
Setara Ghairat | Nonsurgical Treatment Specialist
Videos
Testimonials
Our Doctors
Dr. Laura Musselman
Dr. William El Masri
Dr. Lawrence B. Cohen
Dr. Brian Yeung, N.D.
Dr. Leonard Bienenstock, M.D.
Dr. Chameli Deb, M.D.
Breast
Breast Augmentation
Male Breast Reduction
Breast Reduction
Before & After (Breast Augmentation)
Face
Facelift
Ulthereapy Non-surgical Facelift
Rhinoplasty | Nose Surgery
Chin Surgery
Eyelid Surgery / Blepharoplasty
Forehead Surgery
Otoplasty / Ear Surgery
Facial Scar Revision Surgery
Jeunesse FUE Hair Transplant
Body
Brazilian Butt Lift [BBL] or Gluteoplasty
Abdominoplasty / Tummy Tuck
Liposuction
Body Makeover Surgery
Vaginal Surgery
Weight Loss
Naturopathic Weight Loss
Lap Band Surgery
Weight Loss With Gastric Balloon
Non-Surgical
Non-surgical Skin Treatments
Fillers & Injectables in Toronto
Treatments
Full Face Lift With Ultherapy
Ulthereapy Non-surgical Facelift
Vitamin Injection Therapy
Skin Rejuvenation Therapy
Jeunesse FUE Hair Transplant Treatment in Toronto
Microdermabrasion Treatment in Toronto
Mole Removal Treatment in Toronto
Anti Aging Bio-Identical Hormone Testing and Replacement (BHTR) Toronto
Photo Facial Treatment in Toronto
Derma Filler Esthelis
Eyelash Extensions in Toronto
Chemical Peels in Toronto
Laser Hair Removal
Authoritative Clinical Data, Peer Reviews & White Papers on Laser Hair Removal
Before & After
Blogs
Pricing
Our Pricing
FAQ’s
Cancellation Policy
Forms
La Fontaine Source De Jeunesse
Patient Health/Anesthesia Questionnaire
COVID-19 Questionnaire & Informed Consent – General
Day of Surgery COVID-19 Questionnaire & Informed Consent
Option Weight Loss Clinic
Dermal Filler Informed Consent
Injectable Informed Consent Form
Consent for Sclerotherapy of Varicose and Spider Veins
Contact Us
416-962-4444
About Us
Premises Inspection Committee Report
Cosmetic Surgeons in the GTA
Setara Ghairat | Nonsurgical Treatment Specialist
Videos
Testimonials
Our Doctors
Dr. Laura Musselman
Dr. William El Masri
Dr. Lawrence B. Cohen
Dr. Brian Yeung, N.D.
Dr. Leonard Bienenstock, M.D.
Dr. Chameli Deb, M.D.
Breast
Breast Augmentation
Male Breast Reduction
Breast Reduction
Before & After (Breast Augmentation)
Face
Facelift
Ulthereapy Non-surgical Facelift
Rhinoplasty | Nose Surgery
Chin Surgery
Eyelid Surgery / Blepharoplasty
Forehead Surgery
Otoplasty / Ear Surgery
Facial Scar Revision Surgery
Jeunesse FUE Hair Transplant
Body
Brazilian Butt Lift [BBL] or Gluteoplasty
Abdominoplasty / Tummy Tuck
Liposuction
Body Makeover Surgery
Vaginal Surgery
Weight Loss
Naturopathic Weight Loss
Lap Band Surgery
Weight Loss With Gastric Balloon
Non-Surgical
Non-surgical Skin Treatments
Fillers & Injectables in Toronto
Treatments
Full Face Lift With Ultherapy
Ulthereapy Non-surgical Facelift
Vitamin Injection Therapy
Skin Rejuvenation Therapy
Jeunesse FUE Hair Transplant Treatment in Toronto
Microdermabrasion Treatment in Toronto
Mole Removal Treatment in Toronto
Anti Aging Bio-Identical Hormone Testing and Replacement (BHTR) Toronto
Photo Facial Treatment in Toronto
Derma Filler Esthelis
Eyelash Extensions in Toronto
Chemical Peels in Toronto
Laser Hair Removal
Authoritative Clinical Data, Peer Reviews & White Papers on Laser Hair Removal
Before & After
Blogs
Pricing
Our Pricing
FAQ’s
Cancellation Policy
Forms
La Fontaine Source De Jeunesse
Patient Health/Anesthesia Questionnaire
COVID-19 Questionnaire & Informed Consent – General
Day of Surgery COVID-19 Questionnaire & Informed Consent
Option Weight Loss Clinic
Dermal Filler Informed Consent
Injectable Informed Consent Form
Consent for Sclerotherapy of Varicose and Spider Veins
Contact Us
Menu
About Us
Premises Inspection Committee Report
Cosmetic Surgeons in the GTA
Setara Ghairat | Nonsurgical Treatment Specialist
Videos
Testimonials
Our Doctors
Dr. Laura Musselman
Dr. William El Masri
Dr. Lawrence B. Cohen
Dr. Brian Yeung, N.D.
Dr. Leonard Bienenstock, M.D.
Dr. Chameli Deb, M.D.
Breast
Breast Augmentation
Male Breast Reduction
Breast Reduction
Before & After (Breast Augmentation)
Face
Facelift
Ulthereapy Non-surgical Facelift
Rhinoplasty | Nose Surgery
Chin Surgery
Eyelid Surgery / Blepharoplasty
Forehead Surgery
Otoplasty / Ear Surgery
Facial Scar Revision Surgery
Jeunesse FUE Hair Transplant
Body
Brazilian Butt Lift [BBL] or Gluteoplasty
Abdominoplasty / Tummy Tuck
Liposuction
Body Makeover Surgery
Vaginal Surgery
Weight Loss
Naturopathic Weight Loss
Lap Band Surgery
Weight Loss With Gastric Balloon
Non-Surgical
Non-surgical Skin Treatments
Fillers & Injectables in Toronto
Treatments
Full Face Lift With Ultherapy
Ulthereapy Non-surgical Facelift
Vitamin Injection Therapy
Skin Rejuvenation Therapy
Jeunesse FUE Hair Transplant Treatment in Toronto
Microdermabrasion Treatment in Toronto
Mole Removal Treatment in Toronto
Anti Aging Bio-Identical Hormone Testing and Replacement (BHTR) Toronto
Photo Facial Treatment in Toronto
Derma Filler Esthelis
Eyelash Extensions in Toronto
Chemical Peels in Toronto
Laser Hair Removal
Authoritative Clinical Data, Peer Reviews & White Papers on Laser Hair Removal
Before & After
Blogs
Pricing
Our Pricing
FAQ’s
Cancellation Policy
Forms
La Fontaine Source De Jeunesse
Patient Health/Anesthesia Questionnaire
COVID-19 Questionnaire & Informed Consent – General
Day of Surgery COVID-19 Questionnaire & Informed Consent
Option Weight Loss Clinic
Dermal Filler Informed Consent
Injectable Informed Consent Form
Consent for Sclerotherapy of Varicose and Spider Veins
Contact Us
Dermal Filler Informed Consent
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Full Name
Email
I understand that I will be injected with dermal filler, in the following area(s): The indicated dermal filler has been FDA approved for use in cosmetic treatments for moderate to severe wrinkles around the nose and mouth. I understand this treatment is temporary, and re-injection is necessary after about six months. It has been explained to me that other temporary and more permanent treatments are available. The following complications may occur with the dermal filler injection procedure: Risks: I understand there is a risk of bruising, redness, swelling, pain at the injection site, tenderness, itching, allergic reaction, and raised bumps of skin (nodules). These symptoms are usually mild and typically last a few days but can last up to a few months. In rare cases bruising can last several months and even be permanent. Infection: Post treatment bacterial, viral and/or fungal infections can occur which in most cases are easily treatable but in rare cases a permanent scarring in the area can occur. Effectiveness: Treatments can last anywhere from 4-6 months up to one year. Treatments: I understand more than one injection may be needed to achieve a satisfactory result. Allergic Reactions: In rare cases, there may be an allergic reaction to the injection. There is a risk of scarring. I will follow all aftercare instructions as it is crucial I do so for healing. As dermal fillers are not an exact science, there might be an uneven appearance of the face with some areas more affected by the fillers than others. In most cases this uneven appearance can be corrected by more injections in the same or nearby areas. However, in some cases this uneven appearance can persist for several weeks or months. This list is not meant to be inclusive of all possible risks associated with dermal fillers as there are both known and unknown side effects associated with any medication or procedure. These dermal fillers should not be administered to a pregnant or nursing woman. The number of units injected is an estimate of the amount of dermal filler required to add volume to the skin and give the appearance of a smoother face. I understand there is no guarantee of results of any treatment and the regular charge applies to all subsequent treatments. I understand and agree that all services rendered are charged directly to me and I am personally responsible for payment. I further agree in the event of non-payment, to bear the cost of collection, and/or Court cost and reasonable legal fees should this be required. By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent dermal filler treatments with the above understood. I hereby release the doctor, the person injecting the dermal filler and the facility from liability associated with this procedure.
Date
Consent
By initiating this form, I confirm that my answers are true and have been answered to the best of my ability.
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