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1. What is Lip Rejuvenation?
Lip Rejuvenation is a needle-less procedure which helps increase
hydration and provides volume in your lips using hyaluronic acid.

2. What kind of product do you use?
I use Hyaluronic Acid, A natural sugar found in the human body,
hyaluronic acid is the most hydrating substance in the world. It’s
function is to attract water and keep skin hydrated, plump and

3. How would I know if I am allergic?
As the human body creates Hyaluronic Acid naturally it is impossible
to be allergic to it.

4. How is it administered without a needle?
By using a Hyaluron Pen.

5. What is the Hyaluron Pen?
An innovative method that safely deposits Hyaluronic acid into the
epidermal and upper dermal layers of the skin without the traditional

6. Is it safe?
Still compared to injecting fillers (that the safety of Hyaluron Pen
often gets compared to) it is totally safe.

7. Does it hurt?
The feeling is tolerable. I like to compare it to rubber band snaps.

8. How long does the results last?
Results may vary for each client depending on lifestyle. These will
typically last from 6 to 18 months.

Do you have any allergies?
Are you allergic to lidocaine?
Are you pregnant?
Are you over the age of 18?
Have you ever gotten fillers before?

As a patient, you have requested my administration of a stabilized
hyaluronic acid used in the correction of moderate to severe facial
wrinkles and fold. All medical and cosmetic procedures carry risks and
may cause complications. The purpose of this document is to make you
familiar with the procedure and its risks in advance. This way, you
can decide whether or not to go forward with the process.

THE PROCESS - This product is administered via a syringe, or a special
pen, into the areas of the face. - Anesthesia or a numbing medicine
can be used to reduce the discomfort - The treatment site(s) is washed
first with an antiseptic (cleansing) solution *

RISKS/ DISCOMFORT The service provider has discussed with me, and I
clearly understand that during and after the injection, there are some
potential side effects. Which include and may not be limited to: -
Inflammatory reactions such as redness, edema *

MEDICAL HISTORY I will inform the staff of the service provider of my
medical history, and I clearly understand that I can't get the
treatment if I am Pregnant or breastfeeding, If I am sensitive to
hyaluronic acid. I have severe allergies. In areas being treated. *

OTHER CONSIDERATIONS Patients who have autoimmune conditions or are
significantly inflammatory have a higher chance of inflammatory
reactions. Treatment with HAF must be made on a case by case basis
with a full understanding of the risks. As with all injections *

ALTERNATIVES This is a voluntary cosmetic procedure. No treatment is
necessary or required. Other alternative treatments which vary in
sensitivity, effect, and duration include: animal-derived collagen
filler products, dermal fillers derived from the patient *


I understand that the injector will choose the dermal filler based on
the area to be injected. The injector will recommend the amount of
product required for the best results. Changes in the recommendations
may alter the outcome of the treatment *


CONSENT- My consent and authorization for this procedure are strictly
voluntary. By signing this informed consent form, I hereby grant
authority to the service provider to perform Filler Therapy/Injections
using HAF for the treatment of my condition.


Sign your name below:

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