Informed consent

Non-surgical aesthetic medical treatments

As a patient, you have the right to information about your health condition and the recommended treatment and/or procedure. You can only make a decision about this if you are sufficiently informed about the reason, purpose, duration and nature of the treatment, the degree of urgency and frequency, the contraindications, the side effects both physical and psychological as well as the relevant risks, the possible treatment alternatives, the consequences in case of refusal or withdrawal of consent, the aftercare and recovery period with possible complications and the cost. This information is intended to inform you sufficiently so that you can make a good decision whether or not to undergo the treatment/procedure.

Speak to the doctor if you do not (fully) understand the information. The doctor will make time to answer your additional questions.

Dr. Thierry De Smedt, treating physician, has today:

• given me precise information about my health condition and the diagnosis that makes the proposed treatment(s) useful.
• given me information in simple and understandable terms about the importance of the proposed treatment(s) as well as the possible evolution if the above-mentioned treatment(s) is/are not carried out. The doctor also explained treatment alternatives, if they exist, with their advantages and disadvantages.
• clearly described the nature and purpose of the procedure/treatment, as well as the contraindications, the discomforts that may result from it, as well as the side effects, risks and possible complications of this/these treatment(s) both in the short and long term. Despite the prospect of good results, the chance and nature of complications cannot be precisely predicted, and therefore no guarantees, either express or implied, can be given regarding the success or other outcomes of the treatment (see below).
• also gave me explanation about the aftercare and recovery period. To obtain the best possible aesthetic result, I realize that not following the advice given before, during and after the treatment may not yield an optimal result.
• informed me that the treatment result is temporary. The average duration has been discussed with me. I understand that this is an average and that the duration of the result may vary from person to person.
• explained that during the execution of the treatment(s), the medical team may be forced, due to unforeseeable circumstances, to extend the planned treatment(s) with additional treatments different from those originally agreed upon, but which are absolutely necessary from a medical point of view. I have been given an explanation about the reasonably foreseeable extensions. I therefore give my consent to the doctor to perform all actions during the execution of the planned treatments that are medically necessary for the preservation or restoration of my health condition.
• informed that corrections, so-called touch ups, requiring additional injections of a certain product or another type of treatment, will be invoiced and are not included in the price of the initial correction.

Possible side effects

Possible side effects may include, but are not limited to:

• local swelling of the skin.
• bruising at the injection site.
• redness at the injection site.
• These side effects usually disappear within 24 to 48 hours, or a few days to weeks in the case of a bruise. Small bumps or irregularities may occur but generally disappear on their own. If after two weeks there are still bumps or irregularities, you can contact the practice to have this corrected.

In very rare cases,

• an allergic reaction may occur characterized by skin rash, itching, sneezing, shortness of breath and/or anaphylactic shock.
• vascular complication may arise when a filler is injected into or next to a blood vessel. This causes the skin to receive insufficient oxygen, resulting in severe pain, marbled discoloration of the skin, and pimples and sores.

In these cases, you should immediately contact a doctor or an emergency department.

I understand that the list of possible complications can never be complete.

Cost, photos and file

I also declare that I am aware of a fairly precise estimate of the financial cost of the planned treatment(s), including the provisions regarding the charging of VAT.

It is customary to take photos before and after the treatment(s). This makes the effect of the treatment clearly visible. These photos are the property of the doctor and are never used for commercial purposes unless you explicitly consent to this. We store these photos in your medical file. This file also contains personal data, medical status and treatment history. All information is protected in a secure online environment. Only the doctor and his staff have access to it. As a patient, I have the right to access my file at any time. I hereby consent to the storage of (personal) data, photos and videos in a medical file.

I realize that for this/these treatment(s), despite the best care of the treating physician, the other medical, nursing and care staff, no absolute guarantee of success can be given. I also understand that, for example, complete symmetry cannot be demanded. I am aware that a doctor undertakes an obligation of effort and not an obligation of result.

Reflection period and declarations

I confirm that I know that I have at least a 15-day reflection period and after this period I will inform the treating physician whether the treatment(s) can proceed.

I declare that I have fully informed the doctor about my pre-existing health condition and have honestly answered the questions about it.

I declare that I am aware that a treatment cannot be performed if any of the following situations apply:

• if permanent fillers are present in the treatment area
• after certain surgical procedures of the face (so always mention if facial surgery has taken place in the past)
• if there are unrealistic expectations
• if the patient is younger than 18 years
• if the patient is pregnant
• if the patient is breastfeeding.

Please note: failure to report this can lead to serious side effects for which the doctor can in no way be held liable.

I have had ample opportunity to ask questions and the doctor has answered sufficiently and completely. I have understood the answers well.

I hereby give my consent for the performance of the planned treatment(s) under the conditions set out above.

This document is drawn up in duplicate. Each party (patient and doctor) acknowledges having received a copy. This document will be added to the medical file.