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Dermal Filler Consent
Medical Questionnaire

Terms of your treatment

I confirm that I have been informed that:

The products in the Vycross collection (Juvederm) are a non-animal, hyaluronic acid (sugar based), non-permanent transparent gel with is injected to:

  • Restore facial volume

  • Treat deep skin depressions, face contouring and volume restoration

  • Treat fine lines and medium sized skin depressions as well as enhance and pouting of the lips

  • Treat fine lines and for additional improvement of skin quality attributes such as hydration and elasticity

Treatment with Juvederm Voluma with lidocaine may remain effective for up to 18 months: treatment with Juvederm Volift and Volbella is effective up to 12 months: treatment with Juvederm Volite is proven to improve dermal hydration for up to 9 months. This will vary depending on the skin type, areas treated, quantity of the product injected, the injection technique and lifestyle factors such as sun exposure and smoking.

A touch up session may be recommended after a few weeks of your initial session to increase the effects and maximise the results. You should be aware the products contain 0.3% lidocaine (HCI) which may produce a positive result in anti-doping tests.

After an injection with either one, two, three, four or five of the vycross collection products, inflammatory skin reactions (for example, redness, swelling, rash) which may be accompanied by itchiness or pain on application of pressure, may occur. These reactions may last up to a week. Bruising, lumps or nodules may appear at the injection site. Very rarely, cases of discolouration or lightening at the injection area have been reported. Rare cases of necrosis (cell death), abscesses (collection of pus), granulation (foreign body reaction) and immediate or delayed hypersensitivity (allergic reactions) have been reported after hyaluronic acid injections and/or lidocaine, as have poor or weak filling effects.

After treatment, please avoid extreme facial expressions, alcohol consumption and applying makeup for 12 hours. Please avoid extreme sun exposure, UV light, temperatures below 0 degrees, saunas, steam rooms for 2 weeks after treatment. It is advisable to avoid strenuous activity or exercise up to 24 hours and to avoid massaging the treated area. Try to sleep with your head elevated and avoid sleeping on the injected site for one or two days.

The use, indications, contraindications and possible side effects of Juvederm vycross range have been explained to me. There are specific situations in which one, two, three, four or five Vycross collection products should not be used, this is determined by the medical history. I have accurately and truthfully answered all the questions regarding my previous medical and aesthetic treatment history to the best of my knowledge.

I was given the opportunity to ask questions and I am satisfied with the answers given.

If inflammatory reactions persist for more than one week, or if any of the side effects appear, I will inform my medical practitioner who will treat appropriately. Whilst rare, such side effects may require treatment lasting several months before they disappear.

My medical practioner may use pictures taken before and after my treatment for the follwing purposes. I have seen these pictures and agree or disagree with their use as follows (please tick appropriate boxes)​

Scientific purposes

Media purposes

I certify that I have read and fully understand the above consent form, I have understood the post-injection recommendations and undertake to observe them.

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