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“A regular skin checkup can literally save your life.” Jennifer Krasnoff, MD

Juvéderm injectable gel is a sterile, biodegradable, non-pyrogenic, viscoelastic, clear, colorless, homogenized hyaluronic acid gel implant. It is approved by the United States Food and Drug Administration for the correction of moderate to severe facial wrinkles and folds, such as nasolabial folds and in some patients may last up to a year.

Risks and complications that may be associated with Juvéderm and the implant procedure include, but are not limited to:

  • Facial Bruising, Redness, Swelling, Itching and Pain: I understand that there is a risk of bruising, redness, swelling, itching and pain associated with the procedure. These symptoms are usually mild and last less than a week but can last longer. Patients who are using medications that can prolong bleeding, such as aspirin, warfarin, or certain vitamins and supplements, may experience increased bruising or bleeding at the injection site. 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.
  • Nodules, and palpable material: I understand that there is a risk that small lumps may form under my skin due to the Juvéderm material collecting in one area. I also understand that I may be able to feel the Juvéderm material in the area where the material has been injected. Any foreign material injected into the body may create the possibility of swelling or other local reactions to a filler material.
  • Migration: I understand that the Juvéderm, as with any filler material, may move from the place where it was injected.
  • Infection: As with all transcutaneous procedures, I understand that injection of any filler material carries the risk of infection. There may be an increased risk of infection if you are on immunosuppressive or therapy used to decrease the body’s immune response.
  • Contraindications/Allergic Reactions: I understand that Juvéderm should not be used in patients with severe allergies, a history of anaphylaxis, or history or presence of multiple severe allergies or hypersensitivity to any of the ingredients in Juvéderm. I am aware that Juvederm should not be used in patients with a history of gram-positive bacterial proteins.
  • Keloids/Scarring: I understand that the safety of Juvéderm in patients with known susceptibility to keloid formation or hypertrophic scarring has not been studied.
  • Accidental Injection into a Blood Vessel: I understand that Juvéderm can be accidentally injected into a blood vessel, which may block the blood vessel and cause local tissue damage, or potentially even a heart attack or stroke.
  • Duration of Effect: I understand that the outcome of treatment with Juvéderm will vary among patients. In some instances, additional treatments may be necessary to achieve the desired outcome. The results may last as long as nine months to one year.

Uncertain Risks

  1. No studies of interactions of Juvéderm with drugs or other substances or implants have been conducted.
  2. The safety of Juvéderm for use during pregnancy or in breastfeeding women has not been established.
  3. The use of Juvéderm in patients under 18 years has not been established.
  4. I understand that the safety and effectiveness of treating facial areas other than the nasolabial folds has not been studied: however, this product has been used to enhance the appearance of lips and other facial wrinkles or folds in many other countries. This “off label” aspect of the treatment has been explained to me.

This above list is not meant to be inclusive of all possible risks associated with Juvéderm 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 and agree that all services rendered will be charged directly to me, and I am personally responsible for payment. 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 have discussed the potential risks and benefits of Juvéderm with my doctor. I understand that there is no guarantee of any particular results of any treatment.

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