Beautay

Dermal fillers consent form

Add your clinic details and print a complete dermal filler consent form. It covers the product used, the risks including vascular occlusion, aftercare and the declarations your client signs.

Your clinic details

These appear at the top of the form. Nothing is sent anywhere, it all stays in your browser.

Your professional registration number if you have one.

The number a client should use if something goes wrong outside opening hours.

Choose Save as PDF in the print dialog if you want a file rather than paper.

Your clinic name

Consent to treatment

Consent to Treatment: Dermal Fillers

Client details

Full name
Date of birth
Address
Contact number
Email address

Treatment description

Dermal fillers are injectable gels used to restore volume, soften lines or change the shape and contour of an area of the face. Most fillers used in aesthetic practice are made from hyaluronic acid, a substance that occurs naturally in the skin.

Your practitioner will record the product name, batch number and the volume used in your treatment notes. Results are visible immediately and typically last between six and eighteen months depending on the product and the area treated.

Areas being treated

  • Lips
  • Cheeks and midface
  • Nasolabial folds
  • Marionette lines
  • Chin and jawline
  • Tear trough
  • Other (as recorded in your treatment notes)

Common and expected effects

  • Swelling, which is often most noticeable in the first 48 to 72 hours
  • Bruising, which can last up to two weeks
  • Tenderness and redness at the injection sites
  • Lumps or firmness that usually settle within two weeks
  • Temporary asymmetry while swelling resolves

Serious risks

Vascular occlusion is the most serious complication of filler treatment. It happens when filler blocks or compresses a blood vessel and it requires immediate treatment.

  • Vascular occlusion, which can cause skin death (necrosis) and permanent scarring if not treated promptly
  • Blindness or visual disturbance, which is rare but permanent and has been reported after injection in the face
  • Infection at the injection site, occasionally requiring antibiotics
  • Delayed onset nodules or granulomas, which can appear months after treatment
  • Biofilm formation requiring medical management
  • Allergic or hypersensitivity reaction
  • Migration of product away from the intended area
  • Herpes simplex reactivation (cold sores) following lip treatment

Warning signs after treatment

Contact the clinic immediately if you experience any of the following. Do not wait for your next appointment.

  • Severe or increasing pain that is out of proportion to the treatment
  • Skin that turns white, blue, grey or mottled
  • Any change in your vision
  • Skin that feels cold to the touch in the treated area
  • Blistering or broken skin
  • Spreading redness, heat or discharge

Reasons treatment may not be suitable

  • You are pregnant, breastfeeding or trying to conceive
  • You have an active skin infection, cold sore or inflammation in the treatment area
  • You have a known allergy to hyaluronic acid or lidocaine
  • You have an autoimmune condition or are taking immunosuppressive medication
  • You have a bleeding disorder or take anticoagulant medication
  • You have had dental work in the last two weeks or have it planned in the next two weeks
  • You have a history of keloid scarring
  • You have permanent filler or an unknown product already in the treatment area

Aftercare

  • Avoid touching, massaging or applying pressure to the treated area for 24 hours unless instructed otherwise
  • Avoid strenuous exercise, saunas, steam rooms and sunbeds for 48 hours
  • Avoid alcohol for 24 hours
  • Sleep on your back with your head slightly raised for the first two nights
  • Avoid makeup on the treated area for 12 hours
  • Do not have facials, laser treatment or chemical peels for two weeks
  • Keep the clinic emergency contact number somewhere you can find it

Reversal

Hyaluronic acid fillers can usually be dissolved using an enzyme called hyaluronidase. Dissolving is a separate treatment with its own risks, including allergic reaction, and may be charged separately unless it is being used to manage a complication.

Declaration

Please initial each statement.

  • I have read and understood the information above, including the serious risks and the warning signs to look out for.
  • I know how to contact the clinic urgently and I understand that I must do so immediately if I notice any warning sign listed above.
  • I have had the opportunity to ask questions and I am satisfied with the answers given.
  • I have given a full and accurate medical history, including all medicines, supplements, allergies and any previous filler treatment.
  • I understand that no guarantee has been given about the result and that further treatment may be needed at additional cost.
  • I consent to clinical photographs being taken and stored as part of my treatment record.
  • I consent to the treatment described above.

Client

Signature
Print name
Date

Practitioner

Signature
Print name
Date

Good practice

Getting consent right

  • Record the product name, batch number, expiry and volume used for every treatment. You need this if a complication develops.
  • Make sure the client leaves with a way to contact you urgently, not just your normal opening hours number.
  • Ask about previous filler, including where and when, before treating any area. Unknown product changes how you manage a complication.
  • Have a written complications policy and access to hyaluronidase before you treat.

Important

This template is a starting point, not legal or clinical advice. Review the wording with your insurer or indemnity provider and adapt it to your own practice, products and protocols before you use it with clients.

Other templates

Stop printing consent forms

Beautay sends the right form when the appointment is booked, stores the signed copy against the client record, and prompts you to re-consent at the next visit.

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