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from experienced professionals
“A regular skin checkup can literally save your life.” Jennifer Krasnoff, MD

Restylane is a sterile gel consisting of hyaluronic acid. In the human body, natural hyaluronic acid provides volume and fullness to skin. Medicis, the manufacturer, states that is it biodegradable, safely and completely metabolized by the body.

Restylane is FDA-approved for the treatment of moderate to severe facial wrinkles and folds, such as the lines from your nose to the corners of your mouth (nasolabial folds). It is also used "off label" to build volume in the lips, cheek bones or chin.

Alternatives: There are alternatives to Restylane injections, including no treatment or other facial soft tissue augmentation. Other alternatives include Botox, laser skin 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 may be necessary to maintain the desired effect.

Side effects and complications include but are not limited to:

  • Potential allergic reaction. As with any product, allergies can develop during or after injection.
  • Injection site reactions: a lumpy or “thick” feeling under the skin bruising, redness, itching, pain, tenderness, swelling
  • Injections into the lip area could trigger a recurrence of facial cold sores for patients with a history of cold sores(herpes simplex infections)
  • Precautions and contraindications:
  • Due to potential allergic reaction, Restylane is not recommended for patients with severe allergies or a history of anaphylaxis.
  • 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 herbs(Ginko Biloba, St. John’s Wort)
  • The safety of Restylane in pregnant or breast-feeding women has not been established, and is therefore not recommended for these women.

Consent
I understand the need for local anesthesia to reduce the discomfort of the procedure and consent to the topical application of anesthetic gel and/or injections for a nerve block or local infiltration. I understand the above, and have had the risks, benefits, and alternatives explained to me. My questions have been answered satisfactorily by the doctor or the doctor’s associates. To the best of my knowledge, I am not pregnant or breastfeeding. I understand this is a cosmetic procedure and that full payment today is my responsibility. I give my informed consent for Restylane injection today as well as future treatments as needed.

I understand and agree that all services rendered will be 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 costs and reasonable legal fees, should they be required. By signing below, I acknowledge that I have read the foregoing informed consent, have had the opportunity to discuss any questions that I have with my doctor to my satisfaction, and consent to the treatment described above with its associated risks. I hereby release the doctor, the person performing the Radiesse injection and the facility from liability associated with this procedure.

I agree that pre- & post-operative clinical photographs and videos may be taken to monitor my treatment progress and for patient educational purposes. I understand that my identity will be protected.

I certify that I have read and understand the contents of this consent form. I have been given the opportunity to ask the doctor/staff any questions that I have about the procedure, and all of my questions have been answered. The doctor/staff has explained the procedure and its alternatives to me, and I both understand and accept the risks involved in this procedure.

Please download this PDF form to sign.

 


 

 

 

Petaluma Office
165 Lynch Creek Way
Petaluma, CA 94954
 M-F, 8:00am-5:00pm
(707) 762-5531
Fax: (707) 762-5976

 

 

Hercules Office
500 Alfred Nobel Dr., Ste. 245
Hercules, CA 94547
M-F, 8:00am-5:00pm
Open Saturday for aesthetic services
 (510) 741-7418
Fax: (510) 741-7456

 

Billing office
510-741-7299
Fax: 510- 741-7493

 


At Dermatology Associates of the Bay Area, our board-certified dermatologists serve patients at our Petaluma and Hercules offices. We are committed to the highest standards, and we offer a full range of cosmetic, medical, and surgical dermatology procedures, as well as quality skin care products.

Dermatology Associates of the Bay Area
165 Lynch Creek Way | Petaluma, California 94954 | Phone: (707) 762-5531 | Fax: (707) 762-5976
500 Alfred Nobel Drive, Suite 245 | Hercules, California 94547 | Phone: (510) 741-7418 | Fax: (510) 741-7456