Juvederm® INFORMED CONSENT
Indications. Juvederm® is a sterile gel consisting of stabilized hyaluronic acid;; Medicis, the manufacturer, states that it is
biodegradable, and safely and completely metabolized by the body. Juvederm® injections are given to correct facial wrinkles
and/or for lip augmentation. Juvederm® has been approved by the FDA (Food and Drug Administration) I understand that the
safety and effectiveness of treating facial areas other than the nasolabial folds has not been studied;; however, Juvederm®
has been used to enhance the appearance of lips and wrinkles in over 60 other countries. This “off-label” aspect of the
treatment has been explained to me.
Alternatives. There are alternatives to Juvederm® injections, including no treatment, collagen for lip or other facial soft tissue
augmentation, and cosmetics, 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. I understand
that treatments can last anywhere from 4-6 months up to one year. I understand that more than one injection may be needed
to achieve a satisfactory result.
Risks and Complications
It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and
in this specific instance such risks include but are not limited to:
1) Post treatment discomfort, swelling, redness, bruising, discoloration, tenderness, and itching (These symptoms are
usually mild and typically last a few days but can last up to a few months. In rare cases, bruising can last several months and
even be permanent.)
2) Post treatment bacterial, viral and/or fungal infection associated with any transcutaneous injections which in most cases
are easily treatable but in rare cases a permanent scarring in the area can occur.
3) Allergic reaction. As with any product, allergies can develop during or after injection.
4) Injection into the lip area could cause recurrence of Herpes simplex ( facial cold sores) for patients with a history of prior
5) Lumpiness, visible yellow or white patches in approximately 20% of cases
6) Granuloma formation
7) Localized Necrosis and/ or sloughing, with scab and/or without scab if blood vessel occlusion occurs.
Precautions and contraindications
Due to the potential for an allergic reaction, Juvederm® 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
(Ginkgo Biloba, St. John’s Wart, fish oil).
The safety of Juvederm® in pregnant or breast-feeding women has not been established, and is therefore not
recommended for these women.
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 infiltrative anesthesia. I understand the above, and have had the
risks, benefits, and alternatives explained to me, and have had the opportunity to ask questions. No guarantees about
results have been made. To the best of my knowledge, I am not pregnant, and I am not breastfeeding. I give my informed
consent for Juvederm® injections today as well as future treatments as needed. If you are under 18 years of age we require
a signature of a parent or legal guardian.
I will follow all aftercare instructions as it is crucial for proper healing to take place.
By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its
associated risks. I hereby give consent to perform this and all subsequent Juvederm® treatments with the above
understood. I hereby release the doctor, the person injecting the Juvederm® and the facility from liability associated with this
I have received and understand the pre /post care instructions.
Print Name __________________________________
Patient Signature Date