State-of-the-art, personalized skin care
from experienced professionals
“A regular skin checkup can literally save your life.” Jennifer Krasnoff, MD

Perlane is cosmetic dermal filler that adds volume within the skin. It consists of a hyaluronic acid. In the human body, natural hyaluronic acid provides volume and fullness to skin.

After treatment with Perlane, the hydrophilic, or “water loving”, nature of the hyaluronic acid molecules allows them to bind many times their own weight in water as they slowly break down. This process helps maintain volume for about six months.

Perlane 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). Perlane is also used "off label" to build volume in the lips, cheek bones or chin.

Perlane contains no animal proteins. This may limit the risk of animal –based disease transmission or allergic reactions. Perlane contains trace amounts of gram positive bacterial proteins and is contraindicated for patients with a history of allergies to such material. No allergy testing is required before use.

After your treatment with Perlane, you may have some swelling, redness, pain, bruising, and tenderness. This will normally last less than 7 days.

This above list is not meant to be inclusive of all possible risks associated with Perlane or dermal fillers in general, as there are both known and unknown side effects and complications associated with any medication or dermal filler injection procedure. I understand that medical attention may be required to resolve complications associated with my injection.

I understand that I should minimize exposure of the treated area to the sun or heat for approximately 24 hours after treatment or until any initial swelling or redness goes away.

I have discussed the potential risks and benefits of Perlane with my doctor. I understand that there is no guarantee of any particular results of any treatment.

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 Perlane 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