Patient Information
Treatment Details
Contraindications - Please confirm you do NOT have any of the following:
Pregnancy or breastfeeding
Active skin infection, cold sores (herpes), or inflammation at treatment area
Allergy to hyaluronic acid or lidocaine (if product contains anaesthetic)
History of severe allergies or anaphylaxis
Autoimmune conditions (e.g., lupus, rheumatoid arthritis)
Blood clotting disorders or current anticoagulant therapy
Permanent fillers or implants in the treatment area
Recent dental procedures (within 2 weeks)
VASCULAR OCCLUSION WARNING
Dermal fillers carry a risk of vascular occlusion (blockage of blood vessels) which can cause tissue death or, in rare cases, blindness. I understand that my practitioner is trained to recognise and treat this complication, and that hyaluronidase (dissolving enzyme) is available on-site.
Risks and Potential Complications
I understand that the following risks and complications may occur:
- Common: Bruising, swelling, redness (may last 7-14 days)
- Common: Tenderness at injection sites
- Common: Asymmetry (may require adjustment)
- Uncommon: Lumps or nodules (usually massageable)
- Uncommon: Migration of filler from original site
- Uncommon: Infection requiring antibiotics
- Rare: Vascular occlusion - skin necrosis (tissue death)
- Rare: Vascular occlusion - vision changes or blindness
- Rare: Granuloma formation
- Rare: Severe allergic reaction
Hyaluronidase (Dissolution) Acknowledgement
I understand that hyaluronic acid fillers can be dissolved using hyaluronidase enzyme if complications occur or if I am unhappy with results. I understand this is a separate procedure with its own risks including allergic reaction. I consent to emergency use of hyaluronidase if vascular occlusion is suspected.
Patient Acknowledgements
By signing below, I confirm that:
I have been given adequate time (cooling-off period) to consider this treatment
I have disclosed all relevant medical history, medications, and previous filler treatments
I understand the procedure, expected results, and limitations
I understand that results typically last 6-18 months depending on area and product
I understand the risks including the serious risk of vascular occlusion
I understand I must contact the clinic immediately if I experience unusual pain, blanching, or vision changes
I have received and understood the aftercare instructions
I consent to before and after photographs for my medical records
I am over 18 years of age
Data Protection Notice (GDPR): Your personal and medical information will be stored securely in accordance with UK GDPR and the Data Protection Act 2018. Your data will only be used for the purposes of your treatment and care. You have the right to access, rectify, or request deletion of your data.
I have read and understood this consent form and agree to proceed with treatment.
Practitioner Name (Print)