Juvederm Injection Informed Consent
Juvederm is a colorless hyaluronic acid that is designed to be injected into facial tissue to smooth wrinkles and plump folds. Juvederm is FDA approved for the nasal labial area. Hyaluronic acid is a polysaccharide found naturally in all living organisms, and has the same chemical structure in all species and tissues. In the skin, Hyaluronic acid binds water to add volume and pliability. As we age, our skin loses its ability to produce Hyaluronic acid. Juvederm is injected into the skin to create volume thereby smoothing wrinkles and providing a fuller shape. The effects of Juvederm are temporary, meaning the injection will have to be repeated on a regular basis to maintain the effects. Results typically last 6 months to one year following the injection. Contraindications For This Treatment Include: • Clients with severe allergies, history of anaphylaxis, history of multiple allergies • Patients who have allergies to lidocaine if Juvederm with lidocaine is being used • Clients with a known history of hypertrophic scarring and keloid formation • Pregnancy and nursing mothers • Clients less than 18 years of age • Autoimmune disorders such as Rheumatoid Arthritis and Lupus • Cold sore, blemish, rash, or any inflammation or irritation in the areas to be treated • Permanent implant located in area to be injected • Clients on immunosuppressive therapy • Clients taking medications that decrease their bleeding time are more prone to bleeding and bruising I DO NOT have allergies to lidocaine.
I am aware of the following risks and potential side effects including but not limited to: 1. Mild to moderate discomfort or pain. 2. Swelling, erythema, and tenderness. We recommend icing or using cold compresses (without using pressure over injected areas) post-treatment. 3. Urticaria (itching). 4. Bruising/Infection. Injection-related reactions can include bruising and infection. We recommend clients avoid aspirin and other non-steroidal anti-inflammatory drugs, such as Advil and Motrin that reduce blood clotting time. There is a risk of infection whenever the skin barrier is penetrated. The syringe and needle are sterile and standard precautions are taken with all injections. Should any type of skin infection occur, additional treatment, including antibiotics, may be necessary. Bruising may take up to 3 weeks or longer to heal. 5. Scabbing/Sloughing/Scarring. In less than 1% of treated patients, sloughing of the tissue at the treatment site has been noted. Whenever sloughing occurs, it can result in a shallow scar, which may or may not be permanent. 6. Lumps/Bumps/Hardening at Site. This generally softens over time but can take several months. 7. Migration. As with all fillers, Juvederm may move from the place where it was injected. 8. Allergic Reaction. Although rare, an allergic reaction can occur from agents in the Juvederm. I understand that it is generally recommended to wait 6 weeks to see the final level of correction. If my level of correction is not as I had hoped, I understand that I may need to purchase additional Juvederm (or other filler) for injection to reach a higher level of correction. It is also possible that I may need to wait for the injection to wear off if over-correction resulted. I agree to communicate with American Laser Centers for evaluation and/or additional correction if needed. I acknowledge that due to my unique skin composition, there are no guarantees, warranties, or assurances that I will be satisfied with my results. I understand that this treatment may involve risks of complication from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure. I consent and authorize a staff member of American Laser Centers, who has been trained in Hyaluronic acid injections (Juvederm) to perform hyaluronic acid injections on me. I agree to pay for this treatment. I understand that I have the right to refuse or stop treatment at any time, but that no refunds will be provided once payment is made (including and even if I am dissatisfied with the results of treatment). I certify that I have read this entire informed consent and that I understand and agree to the information provided in this form as well as the information provided in the Pre/Post Care form. I agree to have my photograph taken to document my condition. A member of the American Laser Centers staff has explained the nature of my condition, the nature of the procedure, alternative treatments, and the benefits to be reasonably expected compared with alternative approaches. This document is a written confirmation of this discussion. I agree that this consent supersedes any previous verbal or written disclosures. This consent is valid for all of my Juvederm injections in the future as well.