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Juvederm Consent Form Juvederm is indicated for the temporary improvement in the appearance of facial wrinkles and folds from your nose to the corner of your mouth. The most common side effects include swelling redness pain and bruising of the treated areas. These normally last less than seven days. If you are pregnant breastfeeding or under 18 you should not use these medications. I confirm that prior to treatment I have avoided aspirin medications that thin the blood non-steroidal anti-inflammatory medications St* John s Wort or high doses of Vitamin E* These medications may increase bruising or bleeding at the injection site. I understand that there may be some degree of discomfort with these injections. injections. I hereby agree to all of the above and agree to be treated with / . I further agree to follow all post-treatment instructions. Post Juvederm Instructions 1. Cold compresses may be used immediately after treatment to reduce swelling. 2. Avoid touching the treated area within six hours following treatment so that you do not accidentally injure your skin while the area is numb. After that you may gently wash the area with soap and water. 3. Until there is no redness or swelling avoid exposure of the treated area to intense heat sun lamp or sun bathing. 4. Continue to avoid aspirin medications that thin the blood non-steroidal anti-inflammatory medications St* John s Wort or high doses of Vitamin E* If you have any questions please feel free to call the office at 480 985-0000. Patient Signature Date Witness Signature Date www. EastValleyND. com 5416 E* Southern 110 Mesa AZ 85206 p 480 985-0000 f 480 985-0029. The most common side effects include swelling redness pain and bruising of the treated areas. These normally last less than seven days. If you are pregnant breastfeeding or under 18 you should not use these medications. I confirm that prior to treatment I have avoided aspirin medications that thin the blood non-steroidal anti-inflammatory medications St* John s Wort or high doses of Vitamin E* These medications may increase bruising or bleeding at the injection site. If you are pregnant breastfeeding or under 18 you should not use these medications. I confirm that prior to treatment I have avoided aspirin medications that thin the blood non-steroidal anti-inflammatory medications St* John s Wort or high doses of Vitamin E* These medications may increase bruising or bleeding at the injection site. I understand that there may be some degree of discomfort with these injections. injections. I hereby agree to all of the above and agree to be treated with / . I understand that there may be some degree of discomfort with these injections. injections. I hereby agree to all of the above and agree to be treated with / . I further agree to follow all post-treatment instructions. Post Juvederm Instructions 1. Cold compresses may be used immediately after treatment to reduce swelling. I further agree to follow all post-treatment instructions. Post Juvederm Instructions 1. Cold compresses may be used immediately after treatment to reduce swelling. 2. Avoid touching the treated area within six hours following treatment so that you do not accidentally injure your skin while the area is numb.

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