Juvederm Patient Application

General
FirstName: LastName: Date: Age:
Address: City: State: Zip Code:
Phone Home: Phone Work: Phone Cell:
Date of Birth: Marital Status:
Employer: Occupation:
Emergency Contact: Relationship:
Emergency
Phone Home:		 Emergency
Phone Work:		 Emergency
Phone Cell:
Email Address: (You will be subscribed to our monthly newsletter, you may unsubscribe at any time.)

Health History
Medications:
Allergies:
Surgeries
/Dates:
Have a history of?
Heart Disease Mental Disease Neuro-muscular Disease
Excessive Bleeding Auto-immune Disorders Diabetes
High Blood Pressure Liver Disease Cold Sores/Fever Blisters
Other    
Please explain:
Are you?
Pregnant:

Yes No

Nursing: Yes No
Do you?
Smoke:

Yes No

 Drink Alcohol: Yes No Amount per day:

Post Treatment Instructions
  1. After your treatment, you might have some redness and swelling. This will normally last less than seven days. Cold compresses may be used immediately after treatment to reduce swelling. If the inconvenience continues beyond seven days or if other reactions occur, please contact us at 813-886-4395. Our office will contact you as soon as possible.

  2. Avoid touching the treated area within six hours following treatment. After that, the area can be gently washed.

  3. Sunbathing and cold outdoor activities should be avoided until any redness or swelling disappear.

  4. If you have previously suffered from facial cold sores, there is a risk that the needle punctures could contribute to another recurrence.

  5. Avoid exercise and alcohol for six hours after treatment.

  6. Having a follow-up treatment before the product has fully dissipated may enhance the lasting effect. Please be sure to contact our office at 813-886-4395 about recommendations for touch-up or follow-up treatments.

  7. One week prior to your next treatment with Juve’derm, avoid taking St. John’s Wort, high doses of Vitamin E supplements, aspirin, and other non-steroidal anti-inflammatory medications, such as ibuprofen. These agents may increase bruising and bleeding at the injection site.

For complete product and safety information, please visit www.Allergan.com

The above information is true and accurate to the best of my knowledge.

Patient Signature: Date:
Witness Signature: Date: