The fillers above are sterile inject-able material consisting mainly of: Hyaluronic acids with lidocaine (numbing solution); this is non-permanent and metabolized by the body. Filler injections are given to temporarily correct facial wrinkles, lines, folds, or scars &/or for lip augmentation, &/or replacement of volume to the face, cheeks, orbital rims, etc. Most fillers are also used “off-label” for the lips, eyelids, nose, cheeks, or other facial cosmetic corrections. I understand that the safety and effectiveness of treating facial areas other than the nasolabial folds has not been studied; however, fillers have been extensively used in all areas of the face relatively safely – depending on the filler and the technique.

Alternatives:

There are alternatives to the specific filler injections circled above, including no treatment, collagen or fat injections, or other facial soft tissue augmentations or implants, as well as cosmetics, Botox, laser resurfacing, chemical peels, or plastic surgery for wrinkle reduction.

Results:

I understand that the actual degree of improvement cannot be predicted or guaranteed. Furthermore, I understand that the effect will gradually wear off and additional treatments are necessary to maintain the desired effect. Results depend on the filler as well as the amount or volume of the filler.

Side effects and complications include but are not limited to:

• Potential allergic reaction.  As with any product, allergies can develop during or after injection.  Patients with known allergy to these fillers or certain food allergies or numbing medications should avoid these injections.  Injection site reactions: a lumpy or “thick” feeling at or just under the skin, bruising, hematoma, redness, discoloration, scars, vascular occlusion, itching, pain, nerve damage, infection, over-correction, granulomas, palpable or visible material, tenderness, swelling, asymmetry, or shifting can occur.  Injections into the lip area could trigger a recurrence of facial cold sores (Herpes simplex infections) for the patients with a history of prior cold sores. Lumps or nodules can occur. Filler migration where filler moves outside of the treated location is uncontrollable and can occur.
• I understand results are not guaranteed and further treatment for additional improvement or correction of side effects or complications may be necessary.

Precautions and contraindications:

• Due to the potential for allergic reaction, fillers are not recommended for patients with severe allergies or a history of anaphylaxis to components of the particular filler. The risk of bruising or bleeding may be increased by medications with anticoagulant effects, such as aspirin and non-steroidal anti-inflammatory drugs (e.g., Ibuprofen, Aleve, Motrin, Celebrex), high doses of Vitamin E, and certain herbal supplements (Ginko Biloba, St. John’s Wart, Flaxseed, Omega-3, etc). The safety of fillers in pregnant or breast-feeding woman has not been established and is therefore not recommended for these women.

Consent:

I understand the possible need for local anesthesia to reduce the discomfort of the procedure and consent to the topical application of anesthetic gel and/or injections of anesthetic for a nerve block.  I understand the above, and have had the risks, benefits, and alternatives explained to me, and have had the opportunity to ask questions and refuse treatment.  I have chosen this treatment voluntarily and no guarantees about results have been made.  Further treatments may be needed.  Payments are non-refundable.  To the best of my knowledge, I am not pregnant, and I am not breastfeeding.  I give my informed consent for fillers injections today as well as future treatments as needed.

Your consent and authorization for this elective procedure is strictly voluntary. By signing this informed consent form, you hereby grant authorization to our medical staff to perform and/or to administer any related treatment as may be deemed necessary or advisable in the diagnosis and treatment of your condition.

• The nature and purpose of this elective procedure and the complications and side effects have been fully explained to me. Alternative treatments and their risks and benefits have been explained to me and I understand that I have a right to refuse treatment. I agree to adhere to all safety precautions and instructions after the treatment. I have been instructed in and understand post treatment instructions and have been offered a written copy of them. I understand that no refunds will be given for treatments received. No guarantee has been given by anyone as to the results that may be obtained by this treatment.
• I have read this informed consent and certify that I understand its contents in full. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I have had enough time to consider the information given me and feel that I am sufficiently advised to consent to this procedure. I accept the risks and complications of the procedure. I certify if any changes occur in my medical history I will notify the office.
• I hereby give my voluntary consent to this elective procedure and release the facility, medical staff, and specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age and am not under the influence of alcohol or drugs. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.
• I agree, if I should have any questions or concerns regarding my treatment / results I will notify this office at immediately so that timely follow-up and intervention can be provided.

Financial Agreement

I agree that I am financially responsible for the full payment of service provided.  Payment is expected at the time of service.  I understand these services are non-refundable and that insurance never covers cosmetic procedures.  All other fees are calculated on the actual amount of product used to achieve the desired effect.  I also understand that there will be an additional fee for touch ups.

Cancellation / No Show Policy

A 48-hour notice is required for any appointment changes or cancellations.  A cancellation fee of $100 will be charged for any no shows and for any changes or cancellations made within 48 hours of the appointment day and time. 

We respect our Providers’ time as they are booked out weeks to months ahead, and we have a wait list.  Last-minute cancellations do not allow us time to fill those gaps.  We appreciate your understanding of our cancellation policy. This will allow the Arsenault Aesthetics team to continue to provide the highest quality service for you and future clients, as well as valuing our team members’ time.  

By scheduling an appointment, you are agreeing to our cancellation/no-show policy and having a credit card on file. 

Refund Policy

We do not offer refunds on any services rendered.  Aesthetic results are quite variable from person to person and while we do our best to achieve the desired outcome, it cannot be guaranteed.  Clients are responsible for additional treatments needed to achieve desired results.

Retail Products: We do not offer refunds on products purchased.  Defective products may be exchanged within 14 days for the same product.

No refunds on Gift Card purchases.

Privacy Acknowledgement:

We are required to protect your privacy.

Our Notice of Privacy Policy (NPP) details your rights as a patient and how we may use and/or disclose your protected health information.