Healthcare Patient Juvederm Consent Form

HEALTHCARE PATIENT JUVEDERM CONSENT FORM

Patient Information

Patient Name:   Date of Birth:   Gender:

Insurance Information

Medical History

Please indicate if any of the following apply:

I have a bleeding disorder or take anticoagulant medication.

I am pregnant, breastfeeding, or trying to become pregnant.

I take blood thinners (prescription or OTC) or supplements that increase bleeding risk.

Planned Treatment

Proposed treatment area(s):

Proposed product(s):    Estimated volume:

Planned procedure date:

Risks, Benefits, and Alternatives

I understand that Juvederm is an injectable hyaluronic acid dermal filler used to improve facial wrinkles and restore volume. The intended benefits include temporary improvement in the appearance of treated areas, reduction of lines and wrinkles, and restoration of facial fullness.

Known risks and possible complications include, but are not limited to: pain, bruising, swelling, redness, tenderness, itching, infection, allergic reaction, lumps or nodules, asymmetry, delayed swelling, scarring, hypersensitivity, and the need for additional corrective procedures. Rare but serious risks include inadvertent injection into a blood vessel causing tissue necrosis, stroke, or vision impairment including blindness. I understand that such complications may be permanent and require urgent medical treatment.

Alternatives to treatment include no treatment, other injectable agents, surgical correction, or topical therapies. No guarantee has been made regarding the expected results.

I have been informed of the risks and benefits and have had the opportunity to ask questions regarding the procedure, alternatives, and potential complications. All my questions have been answered to my satisfaction.

Please acknowledge understanding of the above risks and that you have had an opportunity to discuss them with the clinician:

I acknowledge that I understand the risks and benefits described above.

Post-Treatment Care and Acknowledgement

I agree to follow post-treatment instructions provided by the clinician. I acknowledge that activities increasing circulation to the treated area (strenuous exercise, alcohol, exposure to heat) may increase swelling and bruising. I understand I should contact the clinic promptly if I experience severe pain, prolonged redness, progressive swelling, or visual changes.

I have received and understand the post-treatment care instructions.

Photographs and HIPAA Authorization

I authorize the clinician to take clinical photographs for medical records, treatment planning, and intra-office education. Photographs may be used for publication or teaching only if I give separate written consent.

I consent to clinical photography for medical record-keeping.

I acknowledge that the practice may use and disclose my protected health information for treatment, payment, and health care operations as permitted by law. I understand I may revoke this authorization in writing except to the extent action has already been taken in reliance on it.

I acknowledge receipt of the privacy practices and authorize release of information for treatment and billing purposes.

Authorization and Expiration

I voluntarily consent to the administration of Juvederm dermal filler by the treating clinician or authorized personnel. I understand that additional treatments may be necessary to achieve or maintain results and that I may withdraw my consent at any time prior to treatment.

Patient Certification

By signing below I certify that I have read and fully understand this consent form. I attest that the information I have provided in this form is accurate and complete to the best of my knowledge. I accept the risks explained to me and consent to the proposed Juvederm treatment. I understand that no guarantees have been made regarding outcome or duration of effect.

If signing on behalf of patient:

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