Name: Elite Medical Skin and Laser Center
Price range: $$$

Jeanne Southern, M.D.

Medical Director, Elite Medical Skin Care & Laser

JUVEDERM PATIENT CONSENT FORM

Being fully informed about your condition and treatment will help you decide whether or not to undergo an injectable treatment. This disclosure is not meant to alarm you; it is simply an effort to better inform you so that you may give or withhold your consent for this treatment.

Please initial and sign as appropriate:

I certify that I am not pregnant and that I have no significant neurological disease, asthma, HIV, and/or facial herpes. Also, to the best of my knowledge, I certify that I have listed all allergies/sensitivities and that I am not allergic to eggs/egg products or lidocaine. *

I understand that I will be injected with one or more of the Juvederm collection of facial fillers. These fillers are composed of hyaluronic acid in a smooth gel combined with lidocaine anesthetic.

I understand that multiple treatments may be necessary to achieve desired results. As these fillers are broken down naturally by the body, maintenance of the desired effect will be necessary.

I understand that side effects/complications are rare, but occasionally a headache, slight swelling and/or bruising may occur after treatment(s) for a few minutes to several days after injection(s).

Patients with a history of cold sores/fever blisters/herpes may experience an outbreak after the injection. The risk can be minimized by the preventative use of an oral antiviral medication. The need for this medication can be discussed with the physician.

I will be provided a copy of the post-treatment instructions. I understand that compliance with these guidelines is crucial for healing and prevention of side effects or complications.

I consent to the taking of photographs to document progress. My photos will not be used for promotional purposes or public viewing unless I sign a media release form.

Patient Name: *

Date / Time

Date

Time

Have Questions or Need to Schedule An Appointment?

Jeanne Southern, M.D.

JUVEDERM PATIENT CONSENT FORM

Being fully informed about your condition and treatment will help you decide whether or not to undergo an injectable treatment. This disclosure is not meant to alarm you; it is simply an effort to better inform you so that you may give or withhold your consent for this treatment.

Please initial and sign as appropriate:

Visit Us Today

25501 Richards Rd Suite 102 Spring, TX 77386

Get Started Today!

© 2025 All Rights Reserved
Designed by BGDDesigns | ENHANCED by Page-Designs

Have Questions or Need to Schedule An Appointment?

Jeanne Southern, M.D.

JUVEDERM PATIENT CONSENT FORM

Being fully informed about your condition and treatment will help you decide whether or not to undergo an injectable treatment. This disclosure is not meant to alarm you; it is simply an effort to better inform you so that you may give or withhold your consent for this treatment.

Please initial and sign as appropriate:

Visit Us Today

25501 Richards Rd Suite 102 Spring, TX 77386

Get Started Today!

© 2025 All Rights ReservedDesigned by BGDDesigns | ENHANCED by Page-Designs

© 2025 All Rights Reserved
Designed by BGDDesigns | ENHANCED by Page-Designs