1. I consent to and authorize Renew Aesthetics to use injectable fillers to improve the appearance of scars and/or wrinkles, or augment (made larger) areas of the face. The fillers to be used are Juvederm products.
2. The nature and purpose of the treatment has been explained to me and questions I have regarding the treatment have been answered to my satisfaction.
3. I am fully aware of the risks of complications or injuries that can occur from this treatment, both from known and unknown causes and I freely assume those risks.
The known complications could include:
- Redness, swelling/edema, itching
- Pain or pressure lasting more than one week
- Nodules or induration at the injection site
- Discoloration of the injection site
- Poor effect or weak filling or asymmetry
- Allergic reactions
- In extremely rare cases, skin necrosis or "death of skin" may occur as a result of injection into a blood vessel. This may result in financial costs, extended care and scar formation.
4. I also certify that I have none of the known conditions that would contraindicate treatment. These conditions include hypertrophy scars, a history of any autoimmune diseases, Vascular disease, HIV, immune therapy, or psychiatric disease. I am not pregnant, breast-feeding, and I have no known allergy to Hyaluronic acid, anesthetic agents, or bovine source collagen.
5. I certify that I have read this entire informed consent and that I understand and agree to the information stated in this form. I certify that I am a competent adult of at least 18 years of age, or that if I am a minor under the age of 18, I understand that the consent of my parent/legal guardian will also be required before treatment. This informed consent is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns. I agree that any picture taken of my treatment site may be used for publication and teaching purposes, however, my name will not be disclosed and all reasonable attempts to maintain complete confidentiality of my name will be maintained.
6. Furthermore, I completely and totally indemnify Renew Aesthetics, its owner[s], agents, employees, shareholders, and independent contractors from any and all liability in relation to the performance of this procedure[s]. Any clinical follow-up and/or corrections would have to be done at my own cost with the practitioner of my own choosing. Any and all concerns should first be seen in the local emergency room.
7. No guarantee, warranty or assurance have been made to the treatment results.
8. I understand that the results are of temporary nature, and more treatments will be needed to maintain improvement.
9. I agree to adhere to all safety precautions described here including:
- Avoid prolonged sun or UV exposure
- Avoid saunas for two week after injection
- Avoid steam baths for two weeks after injection
- Make up should be avoided for at least 12 hours after injection
10. I agree to pay for the discussed service immediately after treatment.