Fillers Consent Form

I confirm I have been informed that:

Juvederm is a non-animal, hyaluronic acid-based (sugar based), non-permanent transparent gel which is injected to restore facial volume, Treatment with Juvederm may remain effective for up to 18 months but this will vary depending on the skin type, areas treated, quantity of product injected, the injection technique and lifestyle factors such as sun exposure and smoking. A touch up session may be recommended a few weeks after the first session to increase the effects and maximise the results.

Adverse Reactions:

After an injection of Juvederm, inflammatory skin reactions (for example redness, swelling, rash), which may be accompanied by itchiness or pain on application of pressure, may occur. These reactions may last up to a week. Bruising, lumps or nodules may appear at the injection site. Very rarely, cases of discolouration or lightening at the injection area have been reported. Rare cases of necrosis (cell death), abscesses (collection of pus), granulomas (foreign body reaction) and immediate or delayed hypersensitivity (allergic reactions) have also been reported after hyaluronic acid injections and/or lidocaine. If inflammatory reactions persist for more than one week, or if any other side effects appear, I will inform my medical practitioner who will treat appropriately. Whilst rare, such side effects may require treatment lasting several months before they disappear.

After treatment, please avoid extreme facial expressions, alcohol consumption and applying make-up for 12 hours. Please avid sun exposure, UV light, freezing temperatures, saunas and steam rooms for 2 weeks after treatment. It is advisable to avoid strenuous activity or exercise for up to 24 hours and to avoid massaging the treated area. Try to sleep with the head elevated and avoid sleeping on the injected areas for one or two days.

The use, indications, contraindications (specific situations in which Juvederm have been explained to me. There are specific situations in which Jevederm should not be used which can be identified from my medical history. I have accurately and truthfully answered all the questions regarding my previous medical and aesthetic treatment history to the best of my knowledge. If any of the side effects get serious, or if you notice any side effects not listed in this leaflet, please contact Juvea Aesthetics.

Fillers should only be administrated by medically qualified physicians with appropriate qualifications and expertise in this treatment and having the required equipment.

On a voluntary undertaken basis:

My medical practitioner may use pictures taken before and after my treatment for the following purposes. I have seen these pictures and agree or disagree with their use as follows (Please select the appropriate boxes):

I confirm that Dr Uche Aniagwu my treatment practitioner has:

  • - Provided me with sufficient information about the treatment detailed overleaf in order to make an informed decision.
  • - Given me the opportunity to ask all remaining questions I may have about the treatment and has answered them to the best of their ability.
  • - Given me the time to consider the treatment detailed overleaf.
  • - Receive the relevant medical history information from me to the best of my knowledge.

I therefore consent to receiving the described treatment by my treating practitioner: