Client Consent for Dermal Filler/Juvéderm/Teosyal

  • 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.


  • ®Juvéderm is a registered trademark of Allergan Inc.







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