Dermal Filler Consent Form
Sign in to Google to save your progress. Learn more
Your full Name & Surname *
Please confirm, that you have filled Form No. 1 - General Information & Medical Questionnaire. (If no, head back to the form no.1) *
Have you had before any treatment with dermal fillers, absorbable dermal fillers, semi-permanent dermal fillers or botulinum toxin?
*
If yes, which treatment did you receive, what areas were treated and when?
Are you currently taking any steroids, aspirin or anticoagulants (e.g. warfarin etc.)?
*
Do you suffer from acute rheumatic fever or recurrent throat sore?
*
Do you suffer from any allergic reactions, in particular allergies to hyaluronic acid, amide type local anaesthetics or lidocaine?
*
Please read below potential risk, side effects, and after-care procedure: *
Risks and Side Effects

COVID-19 Rarely Dermal Fillers (hyaluronic acid) have been associated with delayed hypersensitivity following influenza like illness. The cause maybe infective or immune mediated in origin. These can present as granulomas, and tender swollen nodules. Whilst we are still learning about COVID-19, due to the similarities to the influenza virus it is possible that the complications listed above may also occur.

Common Risks – 1 in 100 to 1 in 10
• Redness
• Swelling
• Bruising
• Allergic reaction
• Infection
• Discolouration
• Itching
• Pain

Uncommon Risks – 1 in 1,000 to 1 in 100
• Nodules
• Abscess
• Granuloma
• Cyst
• Acne from like lesions
• Unsatisfactory result

Rare Risks – 1 in 10,000 to 1 in 1,000
• Necrosis leading to permanent scar Area Specific Related Risks Temple/tear trough/volumising injections
• Nerve damage/pain
• Blindness Benefits
• Softening/eradication of lines
• Smoother skin
• Restoration of volume
• Smoother facial contours
• Plumper lips
• More youthful appearance

Alternatives
• No treatment
• PRP
• Micro Needling
• Surgery

Aftercare
1. You have undergone a dermal filler treatment where hyaluronic acid has been placed in the skin. You may initially be swollen, red and bruised which will subside within the next 1 -10 days, especially if the bruising is extensive.
2. It is advisable that you do not touch the area for 6 hours.
3. Do not apply make up for approximately 6 hours unless it is mineral based.
4. Avoid exposure to UV and extreme heat i.e. sauna, steam rooms, sun beds etc. as this may increase discomfort and swelling.
5. Also avoid extreme cold: this includes ice packs that are directly applied to the skin. If necessary you can apply a cool compress to the area to reduce any discomfort or swelling.
6. Arnica tablets/gel can be used to help reduce bruising or the application of vitamin k oxide cream.
7. If you have had a local nerve infiltration injection please do not consume any hot or cold drinks until your sensation has returned to normal. You must also be careful when eating so that you do not risk biting your lip.
8. If you experience any lumpiness in the implantation area it can be gently massaged to help smooth this out.
9. You should also avoid any facial massages or skin resurfacing until the area has healed fully.
10. If you feel unsatisfied with the result, a review appointment can be arranged but any additional products used will be charged at the normal price per syringe. 

Consent

I confirm that I have been informed that:

The dermal filler range of products being used are injected into the dermis or deeper to correct the wrinkles, folds and lines of the face and skin, for lip augmentation and to restore volume. You should be aware that the combination of dermal fillers with certain drugs can reduce or inhibit hepatic metabolism (cimetidine, beta-blockers etc) is inadvisable.

The chance of having a side effect is described by the following categories:
Common – More than 1 out of 100 persons and less than 1 out of 10 persons
Uncommon – More than 1 out of 1,000 persons and less than 1 out of 100 persons
Rare – More than 1 out of 10,000 persons and less than 1 out of 1,000 persons

If any of these symptoms persist for more than one week, or if any other side effects develop please report them to the clinician as soon as possible so that they can give advice on the best course of treatment. Whilst rare, such side-effects and their treatment may last several months.

The aesthetic effects of dermal fillers can last up to 12 months but will vary depending on the condition of the skin, product used, area treated, amount of product injected, injection technique and lifestyle factors such as sun exposure and smoking.
The average life treatment in the lips is less than in other areas because of the high vascularisation and action of the lip area. A touch-up procedure may be required 1-3 weeks after injection and helps to optimise the results and maximise the duration of the results.

I confirm that my clinician, has:
- Discussed the risks, benefits and alternatives to this treatment
- Given me the opportunity to ask all remaining questions I have about the treatment
- Given me time to consider the treatment
- Received an accurate medical history and that I have not withheld any information
- Discussed and issued me with specific aftercare pertaining to this treatment.
I therefore consent to receiving the described treatment by my clinician.


TO CONFIRM WRITE DOWN YOUR FULL NAME, SURNAME AND DATE
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy