Patient Information 个人信息

Medical History 医疗历史

Consent Form 同意书

I confirm that I have fully discussed the treatment with my practitioner and understand the following:

• Nature of Treatment: I understand that this is an invasive injection procedure intended to improve facial contours, fill wrinkles, or correct previous filler results.

• Alternatives: I have been informed of available alternatives, including no treatment, surgery, or other non-surgical options.

• Risks: I acknowledge that the treatment carries risks, including but not limited to:

  • Common: Redness, bruising, pain, and swelling at the injection site

  • Uncommon: Infection, allergic reaction, vascular occlusion, skin necrosis, scarring

  • Very Rare: Visual disturbance, tissue necrosis, systemic anaphylaxis

• Specific Risks of Hyaluronidase: I understand that hyaluronidase may cause over-dissolution of filler, skin depression, allergic reactions, and rarely, severe systemic allergic reactions.

• Expectations: I understand that results vary by individual, and fillers will gradually be absorbed over time; additional touch-up treatments may be needed to achieve optimal results.

• Accuracy of Information: I have truthfully disclosed my complete health status, allergies, current medications (including anticoagulants), and previous treatment history.

• Responsibility and Aftercare: I will strictly follow post-treatment care instructions and accept full responsibility for any consequences resulting from failure to follow medical advice or concealment of medical history.

• Consent and Authorization: I understand that I have the right to refuse or stop the treatment at any time. I have received sufficient explanation and all my questions have been answered.

I voluntarily consent to the above treatment, fully understanding its risks and benefits.

本人确认已与医生充分沟通，并理解以下内容：

• 治疗性质： 本人了解该操作为侵入性注射治疗，旨在改善面部轮廓、填充皱纹或纠正之前填充效果。

• 替代方案： 本人已了解其他可行替代方案，包括不进行治疗、外科手术或其他非手术疗法。

• 风险认知： 本人已知晓治疗可能伴随的风险，包括但不限于：

  • 常见：注射部位红肿、淤青、疼痛、肿胀

  • 罕见：感染、过敏反应、血管栓塞、皮肤坏死、瘢痕形成

  • 极罕见：视力障碍、组织坏死、全身性过敏反应

• 溶解酶特定风险： 本人了解透明质酸溶解酶可能导致填充物过度溶解、皮肤凹陷、过敏反应，以及罕见的严重过敏反应。

• 效果预期： 本人了解治疗效果因人而异，且填充剂会随时间逐渐代谢吸收，可能需要后续补充治疗以达到理想效果。

• 信息真实性： 本人已如实告知医生全部健康状况、过敏史、正在服用的药物（包括抗凝药）及既往治疗史。

• 责任与后续护理： 本人将严格遵循术后护理指导，并自行承担因未遵医嘱或隐瞒病史而产生的后果。

• 同意与授权： 本人理解有权在任何时候拒绝或中止治疗。本人已获得充分解释，所有疑问均已得到解答。

本人自愿同意接受上述治疗，并理解其风险与益处。