Dermal Filler Consent Form

I can confirm that my practitioner has explained how and when dermal filler is used and the results to expect. I have been given the opportunity to ask questions and have received satisfactory answers to these questions. I have received information regarding when treatment with dermal filler should not take place and have been informed of precautions and warnings for use with these products and common reactions related to injectables. These reasons include but are not limited to – redness, swelling, pain, itching, bruising and tenderness at the implant location. They usually resolve spontaneously a few days after injection into the skin, within a week of injection into the lips.

I have also been made aware of the risks involved when injecting areas with underlying sensitive structures (e.g. nerves, vessels and eyes when treating wrinkles around eyes).

There are isolated reports of small lumps developing at the treatment sites, and irregularities that can last several months if injection into the skin is too superficial.

Inflammatory reactions have been reported in rare cases consisting of redness, swelling or induration of the injection location, which can at times affect surrounding tissue. Reactions have arisen either a few days/weeks after treatment. These are generally mild – moderate and self-limiting, the average duration is 2 weeks. In rare cases, they have been recurrent and lasted for several months.

Other less common side effects include discolouration, nodules, mass, induration, infection/abscesses, acne-like formations, granuloma, hypersensitivity reactions, ischemia/necrosis, atrophy/scarring, reactions of herpes infection, rash, pruritus, telangiectasia and urticaria.

It is uncommon; however, people may develop infections/inflammations that must be treated with antibiotics and other treatments.

Isolated rare cases of vision abnormalities including blindness have been reported when dermal fillers such as hyaluronic acid are used in areas around the eyes, nose and glabella.

I have been informed that products containing lidocaine must not be used on individuals with known hypersensitivity to lidocaine or amide-type local anaesthetics. Similar to dental anaesthetic, there is a diminished sensation of pain and temperature in the treated area for about 2 hours.

My practitioner has also informed me that topical anaesthetic cream might be used to provide additional pain relief, especially if dermal filler without lidocaine is to be injected. I have received information regarding when/what topical anaesthetics will be used, and information regarding contraindications, warnings/precautions of use of these products and potential side effects.

My treating practitioner has also informed me that, depending on the treated area and injection technique, effects from the dermal filler can last 6 – 12 months, but this period may vary, either longer or shorter. Follow-up treatment helps maintain the desired correction.

I have responded to questions pertaining to any hypersensitivity to aesthetic treatments, including injections, surgeries, chemical peels, etc.