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Dermal Filler Consent Form

This is an informed consent form that has been prepared to help inform you of the potential benefits and risks of dermal filler injections. It is important that you read this information carefully and discuss fully with your practitioner before proceeding with treatment.

It is also important that you take as much time as you need to consider the treatment carefully, weighing up all your options before reaching an informed decision. It is essential that you are aware of your right to have a second opinion and you are encouraged to ask any questions that come to mind throughout the entirety of the process.
Injection of dermal fillers aims to smooth out facial folds and wrinkles, adds volume to the tissues (e.g. lips), and helps to contour facial features. Most dermal fillers used are based on Hyaluronic acid, they may also contain lidocaine, a local anaesthetic to help with pain control.
Hyaluronic acid dermal fillers have been shown to be safe and effective, results can last up to 12 months or longer. After initial treatment, a period of 2 weeks should be allowed for the filler to settle and for residual bruising and swelling to subside. At this 2 week point you may require a small top up if there is any slight unevenness or discrepancy present. There is no guarantee that you will not require additional treatment to achieve the results you seek. Often more than one treatment is needed to achieve desired results. The dermal filler procedure is temporary and additional treatments will be required periodically to maintain results. I am aware the duration of treatment and results are dependent on many factors. I understand the post-treatment instructions, following these will reduce the risk of complications and improve my comfort post treatment.
I understand that several appointments may be necessary to produce optimal results and I will be notified, in advance of each session of treatment, about the location where the next treatment session is going to take place and the identity of who is going to be involved in my care at each stage. I also understand that I will be kept informed of progress and that I can change my mind at any point.
RISKS AND COMPLICATIONS Understanding the risks of dermal filler injections is essential to make an informed decision about your treatment. No procedure is completely risk-free, and all potential risks must be explained before going ahead with treatment. Below are the relevant risks and complications associated with dermal fillers.
Common complications
These include pain, bleeding and bruising at the time of injection. After injection, the area may feel tender but should not be actively painful. If you experience significant pain following dermal filler injection, then you must contact your practitioner as soon as possible for review. Bruising is a common problem; the degree of bruising is dependent on several factors. Most of the time bruising is mild but occasionally can be more significant. Bruising can take up to 2 weeks to fully resolve but should be much improved after 1 week. More uncommonly severe bruising can lead to haematoma formation, a collection of clotted blood. In this case the swollen collection of blood will need at least 2 weeks to resolve naturally and your practitioner will give you the appropriate after care advice. Swelling is another common side effect following dermal filler this is usually mild to moderate but occasionally swelling can be more severe. Swelling is often worse on days 2-3 after injections, it should resolve by 2 weeks but should be significantly improved after 5 days. Sometimes people can faint or feel faint with injections, you must tell your practitioner as soon as possible if you feel unwell during the treatment.
Uncommon complications include- skin infection (cellulitis) which presents as hot, red, shiny skin and you may also be generally unwell. In the case of suspected infection following dermal filler, you should contact your practitioner but also seek medical assessment as soon as possible as you will likely need antibiotics. Occasionally infection can form a swollen collection called an abscess. In this case you again must seek urgent medical attention. If you suffer from cold sores (a herpes virus infection of the lip) these can sometimes be reactivated following a lip filler. Dermal filler can lead to lumps or nodules and sometimes there may be unevenness or poor cosmetic result. You may not achieve the results you desire, especially with one treatment. Filler can occasionally migrate over time and lead to a poor cosmetic appearance, you may require filler dissolving injections to remove migration if it becomes very noticeable or persistent. Occasionally people can develop an unwanted inflammatory reaction to the dermal filler and this can lead to nodule formation called granuloma. These often present as a delayed complication several months after the treatment. Several treatment options are available for granuloma formation and you may require medical assessment. Dermal filler can sometimes cause skin discolouration (Tyndall effect) if accidentally injected too superficially. If this occurs, then you will likely require dissolving injections to remove the filler causing the discolouration.
Rare complications include allergic reaction to the dermal filler or lidocaine anaesthetic, if this a component of the product. Very rarely clients may develop an anaphylactic reaction which would require emergency medical assistance and transfer to hospital. Rarely dermal filler can be injected into an artery blocking the flow of blood to the tissue being treated. This is known as vascular occlusion, if untreated it is serious because it can lead to death of tissue (necrosis) which may require reconstructive surgery to correct. In the rare event of vascular occlusion, it would be treated with emergency injections of a filler dissolving drug called Hyaluronidase. This is an enzyme that removes the filler occluding the blood vessel and can usually fully reverse the vascular occlusion leading to no long-term harmful effects. Your practitioner will be trained in how to use Hyaluronidase in an emergency, however if treatment with Hyaluronidase is not successful then you would require urgent medical assessment or assessment by a doctor who is a specialist in aesthetic medicine.
Finally, the rarest of all complications of dermal filler is called filler blindness. This is where a small amount of filler can be injected into a blood vessel, break off and travel within the circulation (embolisation) and cause blockage of the artery or vein supplying the back of the eye. There have been less than 200 cases reported worldwide but you must be aware of this risk especially if you are receiving nasal or glabella fillers. Filler blindness is irreversible in most cases, in the event of this complication you should seek urgent assessment at the nearest eye hospital or medical eye unit.
I have been advised of the relevant information associated with this treatment and I confirm that I fully understand this advice. This includes advice about:
- the aims/motivations for having the procedure and the desired outcome
- the risks inherent in the procedure
- the risks inherent in refusing the procedure
- the risks specific to me
- the expected benefits of the treatment
- the potential disadvantages of the treatment
- alternative procedures and their pros and cons - including the option of no treatment at all
- any uncertainties about and the likelihood of success of the procedure
- any follow-up treatment that may be required
CLINICAL PHOTOS AND VIDEOS: I agree to and authorise the taking of clinical photographs and videos. I understand that these clinical photographs and videos will form part of and will be kept with my confidential medical records.
I have been asked what information I want and would need in order to make an informed decision. I have been given the opportunity to discuss my desired outcome fully in order for me to make an informed decision.
I certify that I have read the above consent and that I fully understand it. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction. No new information has become available that affects my decision to have the treatment or my decision to consent. I hereby consent to this procedure. This constitutes the full disclosure and supersedes any previous verbal or written disclosures.
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The following aftercare advice is essential to help reduce the risk of treatment
complications, to improve your comfort/healing and to help achieve the best possible
results from treatment.
Please follow the aftercare advice for dermal filler injections.
• Immediately after dermal filler injections the treatment area may be red, tender or
swollen. The redness and tenderness should improve after 48 hours. Swelling is
often worse on days 2-3 after injection, improved by day 5 and resolved by 2
• For significant swelling contact your practitioner for advice. Swelling may be
reduced by regular cold compress, anti-inflammatory medicines such as
Ibuprofen (after 24 hours, if safe for you to take), antihistamines and sleeping
with your head propped up on 3 pillows to help drainage of fluid overnight.
• Bruising is common following treatment; this will resolve naturally but may take
up to 2 weeks to settle.
• Regular application of Arnica cream may be helpful for bruising.
• Tenderness is normal when the injected area is touched afterwards but active
pain at rest is not normal. If you experience pain, you must contact your
practitioner as soon as possible.
• Avoid any makeup for 24 hours after treatment as this will reduce the risk of
• You may require a top up appointment if there is some mild unevenness or
discrepancies noticed once the initial swelling has resolved. Top ups should not
be done until 2 weeks, this is when all post-injection swelling would have
• Drink plenty of water after treatment to keep well hydrated.
• Avoid alcohol, caffeine, hot drinks and spicy food for 24 hours.
• Avoid medications such as aspirin or Ibuprofen for 24 hours as they are blood
thinning agents and may worsen bruising (if these medications have been
advised by your GP you must check with your GP before stopping them)
• Avoid supplements such as multivitamins, fish oils, glucosamine and Vitamin B or
Vitamin E, which are blood thinning agents and may exacerbate bruising for 24
hours (if these supplements have been advised by your GP please check with
your GP before stopping them)
• Avoid any excess sun exposure, extremes of hot/cold, saunas, swimming or
strenuous exercise until the redness and swelling has settled.

• A rare complication of dermal fillers is vascular occlusion in which a blood vessel
is accidentally blocked with filler. Signs and symptoms include throbbing and
aching pain which can be severe, paleness, a cold feeling to the tissue and
purple streaky mottling tissue changes. If you notice any of these symptoms you
must contact your practitioner as soon as possible, they will guide you through
how to perform a capillary refill test and then assess you fully and advise further
action if required.
• You must seek medical attention and contact your practitioner if you experience
any signs or symptoms of infection after treatment. Infection can present as hot,
red shiny skin, there may be pus formation and you may have a fever or feel
generally unwell.
• You must seek emergency medical attention if you experience any severe allergy
symptoms after treatment. Symptoms may include rash, facial swelling and
breathing difficulties.
• You must contact your practitioner as an emergency is you notice any visual
disturbance or loss of vision after the filler injections.
• Contact your practitioner as soon as possible if you notice any other unwanted
side effects.
• Results can be assessed at 2 weeks, by when any residual swelling will have
It is essential that you have read all of the information available. Once you have read and
understood all of the below, please sign the declaration at the bottom of this form. Please
do let your practitioner know if you have any questions or if you do not understand any of
the aftercare instructions provided below.
I confirm that I have read and understood all the information on this Form and that I have
been given the opportunity to ask any questions that have come to mind throughout.

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