Facial Sculpting

HA Fillers Consent Form


Patient Name:  

Date of Birth:  

Temporary Dermal Fillers Consent Form- Hyaluronic Acid (Face)

is a sterile gel consisting of non-animal, stabilised hyaluronic acid and a local anaesthetic called lidocaine. Hyaluronic acid is a sugar chain molecule, naturally occurring in the skin and throughout the body. The sterile gel is injected into the skin to correct facial lines, wrinkles and folds, for lip enhancement, for shaping facial contours including chin, cheeks, jawline and the nose and for skin rejuvenation.

Common Side Effects Associated with the Injection

  • Pain or stinging sensation when the injection is performed.

  • Localized swelling, redness and or tenderness

  • Bleeding at the sites of injection

  • Bruising. Rarely, bruising may be severe and may persist for several weeks.

  • Numbness or itching of the area following injection.


Common side effects are expected to resolve spontaneously, within the first few days of treatment. Whilst not expected, it is possible that reactions described may persist for longer than expected and may inhibit your confidence to attend work or social events. You are advised to schedule treatment with this in mind, allowing time for common reactions such as bruising and swelling, to settle.

Uncommon Side Effects

  • Infection

  • Inflammation

  • Skin discoloration

  • Infection or skin discoloration may occur within a few days, or weeks to months following treatment.

  • Allergic or sensitivity reaction. Symptoms include; itching, rash, red itchy welts, wheezing, asthma symptoms, dizziness or feeling faint. Abscess formation

  • Prolonged swelling which may occur early or present after several weeks

  • Persistent lumps, nodules or papules

  • Acne like formations

  • A Foreign body reaction known as ‘granuloma’ presenting as lumps or nodules

  • The blood supply to the skin may be interrupted by swelling or inadvertent injection into a vessel, causing pain, skin damage and possible scarring.

  • Though extremely rare, transient visual disturbance or permanent blindness has been reported following injectable cosmetic treatment.

Perfect symmetry is not always achievable.

Correction is expected to last for a period of 6-12 months. The successful outcome varies by degree and how long it lasts varies from one individual to another and cannot be guaranteed.

On occasion it is helpful to share visual images of our own treatment results. I consent to photographs being published for;

I have been advised the cost of the treatment will be £ and accept the terms of payment as per the clinic policy (terms and conditions).

Date:  

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Signed by Nina Bal
Signed On: 8th January 2020

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Document name: HA Fillers Consent Form
lock iconUnique Document ID: b2eb4496f1d026cc81b6f34b173579dffa8ff96c
Timestamp Audit
7th November 2019 2:23 pm BSTHA Fillers Consent Form Uploaded by Nina Bal - info@facialsculpting.co.uk IP 51.179.98.227