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This consent form is designed to give you the information you need to make an informed decision about whether or not to undergo treatment with Hyaluronic acid dermal filler (Juvederm/ Revanesse) for facial wrinkles and folds, contour defects, and/or lip enhancement. If you have any questions, please ask Jennifer Iskandar RN, BScN


Hyaluronic acid treatments involve injection of purified hyaluronic acid into the skin to fill wrinkles and restore volume. No skin testing is needed prior to treatment. Just like natural hyaluronic acid, injectable Hyaluronic acid eventually loses its form and wears down. The effects of injectable Hyaluronic acid can last 6 months or longer and ongoing treatments are required to maintain the improvements. However, due to various factors that influence Hyaluronic acid breakdown, no guarantees can be made regarding how long correction will last in a specific patient.



Patients with the following conditions may not receive Hyaluronic acid treatments: previous allergic reactions to injectable hyaluronic products, history of a serious allergic reaction (anaphylactic), multiple severe allergies, abnormal raised scarring or keloid formation, active inflammation, infection in the treatment area (e.g. pimples, rash, hives), pregnancy, or nursing or recent dental/facial surgery. Individuals who have recurrent viral infections such as herpes simplex (cold sores) as it may be activated by Hyaluronic treatments. The injectors must be notified of these conditions prior to treatments.


The possible risks, side effects, and complications with Hyaluronic acid include, but are not limited to:

  1. Pain and tenderness during and after treatments at/around the treated site that typically resolves within a few days to a week.
  2. Redness and swelling at/around the injection site is common. Itchiness may also occur. These reactions are generally present immediately after treatment and lessen or disappear within a few days to 1 week. Some patients may experience prolonged swelling and/or tenderness/pain at the injection site lasting up to 2 weeks. Some patients may experience a delayed onset of these symptoms up to several weeks after treatment. On rare occasions, pustules (acne-like lesions) may form. The injector must be notified if symptoms persist for more than 1 week. Bruising which usually resolves within 1-2 weeks after the injection. Patients taking medications that interfere with coagulation (e.g. aspirin, ibuprofen) have an increased risk of bruising and bleeding.
  3. Infection at the treated site. This may require antibiotics and, rarely, open drainage.
  4. Although rare, local tissue damage can occur with skin breakdown, scab formation, and/or scarring in the treated area.
  5. Visible raised areas and lumpiness at/around the treated site grayish discoloration of the skin. These symptoms may persist from a few weeks to several months and may be permanent (rarely).
  6. Failure to reduce a contour defect or wrinkle (under correction) or overcorrection. Placement of filler adjacent to or outside the desired treatment area; undesired changes in facial contour. Asymmetry, where the correction on one side may be different from the correction on the other side of the face. Swelling at time of injection my created the appearance of asymmetry or under correction with usually resolves as described above. However, you may need to return for additional treatment if under correction or asymmetry persists.
  7. Hyaluronic acid may have an unpredictable duration of action and may not last as long as anticipated or may persist in some areas longer than anticipated.
  8. A remote and rare risk is that of injection of Hyaluronic acid into a blood vessel which can block blood flow in the treated area or in distant areas causing tissue damage which may require surgical correction.
  9. All the risks of Hyaluronic acid may not be known. Dr. Lacey and his staff are not responsible for any Hyaluronic acid risk or unforeseen complication not yet discovered or not commonly known.
  10. If the filler is injected into a vessel, it can occlude the vessel therefore blocking circulation - in very rare occasions if the filler is injected into the retinal artery and/ or travels into the opthalmic artery it can cause blindness (partial, or total).

I consent to administration of any related treatments that may be deemed necessary or advisable for my procedure. This includes, but is not limited to, local anesthetic such as lidocaine. The risks, side effects complications of these anesthetics include, but are not limited to, skin irritation (itching or redness), and tongue numbness. I do not have an allergy to lidocaine or anesthetics. 

 No guarantees can be made or have been made that I will benefit from treatment or achieve a desired level of correction. There is no guarantee wrinkles or folds will be reduced. I understand that I may require additional treatments to achieve correction. I understand that the fees for hyaluronic acid treatments are not covered by insurance. Should I require a touch-up treatment, I am responsible for the cost of that additional treatment. 

I consent to having my photos taken before and after treatment. These photos are part of my medical record.

 I have fully disclosed all my medical history. I understand that it is my responsibility to inform and update the physician or registered nurse of any change in my health status and medical history.

I am an adult of at least 18 years of age. My signature below certifies that I have fully read this consent form and understand the information provided to me regarding the proposed procedure. I have been adequately informed about the procedure involving the potential benefits, limitations and alternative treatments. I have had enough time to consider the information, and I have had all questions and concerns answered to my satisfaction. I understand and accept the risks, side effects, and possible complications associate with Hyaluronic acid treatment.

I consent and authorize a trained physician or registered nurse to perform Hyaluronic acid injection treatments. This consent shall apply to all future Hyaluronic Acid treatments.

 Should I have any questions or problems after treatments, I will call the office.

I have been informed in a way that I understand:

  1. The above treatment or procedure to be undertake
  2. There are risks to the procedure or treatment proposed

By signing this form I consent and understand all the above information and I am satisfied with the explanations.


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