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Hyaluron Pen Consent Form -Form Fill

Section One
Q1

Pain and tenderness at or around the treated area that typically resolves within a few days to a week.*
Q2

Itchiness, redness, and/or swelling at or around the injection may occur. This occurence is normal and happens immediately after treatment and will disappear after a few days or up to a week. Some patients may experience prolonged swelling and/or tenderness/pain at the injection site lasting up to several weeks.*
Q3

In rare occasions, pustules (acne-like lesions) may form.*
Q4

Persons taking medications have a higher risk of bruising and bleeding.*
Q5

Infection may happen at the treated area*
Q6

There are very rare cases where the injection of Hyaluronic cid into a blood vessel would cause to block the blood flow in the treated area or in distant areas causing tissue damage*
Q7

Grayish discoloration on the treated area of the skin.*
Q8

Asymmetry, where the correction on one side may be different from the correction on the other side of the face*
Q9

Date

Date
Q10

Name

First Name
Q11

Name

Last Name
Q12

Phone Number
Q13

Signature