Informed Consent Form For The Temporary Treatment With Injectable Dermal Fillers Page 2

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5. No guarantee, warranty or assurance has been made as to the treatment results. __________
6. I understand that the results are of temporary nature, and more treatments will be needed to maintain
improvement. I agree to adhere to all safety precautions described here including: ___________
 Avoiding prolonged sun or UV exposure
 Avoiding saunas for two weeks after the injection
 Avoiding steam baths for two weeks after injection
 Make-up (which requires vigorous rubbing to apply) should be avoided for at least 12 hours
after injection.
8. I agree to pay ______________ for the above-mentioned services. __________
Patient Name (please print) ________________________________________ Date ___________________
Signature_______________________________________________________ Date ___________________
Witness Signature ________________________________________________ Date ___________________
Revised 3/28/2014 DH
Juvaderm Consent Form

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