I clearly understand that: Juvéderm®/Teosyal is a cross-linked Hyaluronic acid of non-animal origin. Juvéderm®/Teosyal is injected via a syringe into the dermis (skin) to temporarily correct fine lines, wrinkles, folds and contours of the face or to temporarily increase the volume of the lips. Juvéderm®/Teosyal provides correction for an average of 6 months. This effect varies depending on the type of skin, areas of injection, amount injected and injection technique. The longevity of the effect of Juvéderm®/Teosyal in the lips may be reduced because of the high vascularisation of the lips. A touch-up procedure a few weeks after the first injection may help increase persistence and optimize results. A local anesthetic will be administered as necessary by the Physician/Nurse Injector. I clearly understand that after injection of Juvéderm®/Teosyal, there are some potential side effects which include and may not be limited to the following: Inflammatory reactions such as redness, edema and/or erythema, which may be accompanied by stinging, pain or pressure. These reactions may last up to one week. Swelling or nodules may develop at the injection site. Very rare cases of discolouration of the injection site have been reported. Rare cases of necrosis in the glabellar region. Abscess, granuloma or hypersensitivity has been reported after injections of Hyaluronic acid. Persistence of inflammatory reactions for more than one week or the development of any other side effect must be reported to the Physician/Nurse Injector as soon as possible. Increase of bruising or bleeding at the injection site if using a substance such as acetylsalicylic acid or ibuprofen. I have informed my Physician/Nurse Injector/healthcare provider of my medical history and I clearly understand that I cannot be treated with Juvéderm®/Teosyal: If I am pregnant or breast-feeding In areas presenting with inflammatory and/or infections skin problems (acne, etc.) If I have a past history of autoimmune disease If I am receiving immunotherapy treatments If I have a known hypersensitivity to Hyaluronic acid If I am undergoing laser therapy, chemical peeling or dermabrasion If I have a tendency to develop hypertrophic scarring I have informed my Physician/Nurse Injector about all of the medications that I have taken or am currently taking including herbal medications (i.e. ginseng). I have read the information provided in the record of consultation for Juvéderm®/Teosyal in its entirety and have discussed the risks and benefits of Juvéderm®/Teosyal with my Physician/Nurse Injector/healthcare provider or her representative. I understand the information provided. Consent* The use, indications, contraindications and potential adverse effects of treatment with the Juvéderm® and/or Teosyal range of products have been explained to me. I understand the information provided. I have answered all questions regarding my medical history truthfully. I have discussed the risks and benefits of Juvéderm® and/or Teosyal with my Physician/Nurse Injector/healthcare professional and have received satisfactory answers.Consent* I also understand that once I’ve had my treatment there are NO REFUNDS and NO GUARANTEES.Consent* I consent to injection of Juvéderm®/Teosyal.Photographs* I authorize the taking of clinical photographs and their use for scientific purposes both in publications and presentations. I understand that my identity will be protected.Payment* I understand that this is a cosmetic procedure and that payment is my responsibility.Payment Types* I understand that payment is my responsibility and that cheques and American Express are NOT accepted.®Juvéderm is a registered trademark of Allergan Inc.Name First Last Date MM slash DD slash YYYY Signature* Reset signature Signature locked. Reset to sign again