Hyaluronic Acid Dermal Filler Consent Form

Hyaluronic acid dermal fillers are a sterile gel consisting of non-animal cross-linked hyaluronic acid for injection into the skin to temporarily reduce the appearance of facial lines, wrinkles and folds, for lip enhancement and for shaping facial contours. Hyaluronic acid is a naturally occurring sugar found in the human body. The role of hyaluronic acid in the skin is to deliver nutrients, hydrate the skin by holding it in water, and act as a cushioning agent. The effects of hyaluronic acid dermal filler will generally last between 6 - 18 months. However, no guarantee can be given for its duration as the product can be affected by internal and external influences, including medical conditions, medications, smoking and sun exposure.

Treatment

A topical anaesthetic cream is applied 30 minutes before your treatment. For maximum effect and greater comfort during the procedure, it is advised that you see your practitioner 30 minutes before the actual treatment.

Please note your practitioner may inject or add lidocaine to the dermal filler for increased comfort.

Lidocaine is a local anaesthetic that significantly improves discomfort, particularly in the lips. However, there are some potential risks with this medication that you should be aware of:

  • You may test positive in athletic anti-doping tests.

  • You may bruise more easily, increasing downtime.

  • You may experience mild drowsiness after the procedure, and you should not drive or operate heavy machinery if you feel affected by this.

  • You could have an allergic reaction or anaphylactic shock, possibly requiring hospitalisation.

Your treatment involves a series of injections into the facial tissues with hyaluronic acid dermal filler, which usually takes 30 - 60 minutes to complete.

The treatment results will be visible immediately. However, this should not be seen as your final result, as some skin tissue swelling may add to the filling effect. The final treatment result will be best seen 14 days after treatment when any residual swelling or bruising should have subsided. Exceptionally rarely, there can be little or no effect, and further treatment with hyaluronic acid dermal filler may be required at an additional cost.

Aftercare

Immediately following your procedure, slight redness and mild swelling around the treated areas are normal. These signs generally subside within 48 hours. The treated area will feel slightly tender to touch or with extreme facial expression. This can last 2-3 weeks. If bruising occurs, it will typically resolve over 5-10 days. Applying Arnica gel or bruise creams may help with a quicker recovery.

Should you experience any unexpected side effects or any that concern you, please get in touch with the clinic on 01844 278362 as soon as possible. If it is outside clinic hours and you require urgent advice, please call our out-of-hours phone line on 07539 027221. You will be sent an email with this information

What to do after treatment

Do sleep with a few extra pillows at night for the first 1-2 days. This will help to minimise morning swelling.

For the first 48 hours, take extra care and be gentle when cleansing and applying products to the treated area.

What NOT to do after treatment

DO NOT touch or wear make-up in the treated areas for 12 hours.

Avoid strenuous or excessive exercise and swimming for 24 hours

Do not massage or manipulate the treated areas (unless advised by your practitioner), and avoid facial treatments and massage for two weeks.

Avoid extended sun and UV exposure (including sun beds) and temperatures below 0 degrees for two weeks.

Avoid heat treatments such as sauna and steam for two weeks.

What to watch out for after treatment

Severe pain or increasing swelling are NOT normal and should be reported to the clinic immediately.

Immediately report a rash or skin discolouration, including blue, grey, or white mottling, to the clinic. You may require emergency treatment.

PLEASE NOTE:

Should you experience difficulty breathing or swallowing following treatment with dermal filler, you must attend to your local hospital emergency department and contact your practitioner.

Occasionally, you may require further treatment to obtain the desired results. You will be offered a follow-up appointment for four weeks after your initial procedure. It is essential that you attend this follow-up appointment following your first treatment with dermal filler so that the final result can be assessed. Any additional treatment that is required will incur an additional charge and will be discussed with you before any additional treatment is given.  

Alternative Treatments

Other treatments for skin rejuvenation or soft tissue augmentation are available and may be discussed with your practitioner at any time. If you feel that the risks and side effects associated with hyaluronic acid dermal fillers are not acceptable to you, you should consider discussing an alternative treatment with your practitioner or no treatment at all.

Contraindications:

You cannot have treatment with hyaluronic acid dermal fillers if:

  • You are under 18 years of age.

  • You have a known hypersensitivity to hyaluronic acid or lidocaine.

  • You have an active infection or inflammation near the intended treatment area.

  • You have been diagnosed with Body Dysmorphic Disorder (BDD). In rare circumstances, and where we receive written support for your treatment from a mental health professional, we may provide dermal filler treatments. Failure to notify us of a BDD diagnosis could result in extreme dissatisfaction, anxiety and increased symptoms of BDD.

  • You think you could be pregnant, are pregnant, or are lactating or breastfeeding. There are no adequate and well-controlled studies of dermal filler in pregnant or nursing women. Therefore, safety cannot be guaranteed.

Cautions:

You need to tell your aesthetic practitioner if:

  • You are taking blood thinning medications. There is a high risk of bruising.

  • You are taking retinoid medications.

  • You are on immunosuppressive therapy, or therapy used to decrease the body’s immune response.

  • You have diabetes.

  • You suffer from keloid or hypertrophic scarring

  • You suffer from cold sores. 

Material Risk (the level of significance you personally apply to the risks, side effects or complications of this treatment within your own circumstances):

As with any medical procedure, this treatment carries the risk of side effects or complications. Discuss these risks with your practitioner to fully comprehend their implications. Consider the risks in relation to your personal circumstances, including your health, lifestyle and career and decide if they are acceptable. If not, discuss alternatives or take more time to decide.

Associated Risks:

  • Injection site bruising, pain, swelling, rash, local numbness. These symptoms are usually mild and last less than a week but can last longer. Patients who are using medications that can prolong bleeding, such as aspirin, warfarin, or certain vitamins and supplements, may experience increased bruising or bleeding at the injection site. Swelling can be reduced with a cold compress and by ensuring you sleep with your head elevated for the first night after your treatment.

  • Little to no effect. Shorter or longer duration of effect. Hyaluronic acid dermal fillers are generally a successful treatment for volume loss, facial folds and wrinkles. Rarely, there may be little to no effect, or the effect may be shorter or longer than expected. This rarely occurs; however, should you feel this has happened, you must speak with your practitioner.

  • Asymmetry and dissatisfaction with the result. Whilst your practitioner is trained in the successful delivery of dermal filler, there is a risk that you may dislike its effect or feel that you have asymmetry in your treatment result. If this should occur, it is important to speak with your practitioner, as it may be possible to provide corrective treatment.

  • Tyndall effect. You may see a bluish tinge in the area where the material has been injected. This is known as the Tyndall phenomenon and is caused by superficial hyaluronic acid filler reflecting light off the material particles. Your practitioner can easily rectify this should it occur.

  • Acne-like formations.

  • Herpes (cold sores) re-activation. Injection of any filler material carries the risk that an outbreak of herpes (fever blisters/cold sores/shingles) may occur in individuals who already carry the herpes virus. You should manage this as you would normally, such as using over the counter cold sore medication, however we advise that you please contact your practitioner as soon as possible, in case of any potential to distort the dermal filler appearance.

  • Infection. As with any procedure that involves a break to the skin’s surface, an injection of hyaluronic acid dermal filler carries the risk of infection. You should inform your practitioner if swelling, heat, and/or discomfort occur in the treated area for longer than a few days or suddenly occur weeks or months after the procedure. This may require medical intervention from your practitioner, such as antibiotic therapy.

  • Nodules, migration of filler material, and palpable filler material. There is a risk that dermal filer material could migrate to an unintended area or depth of your skin. There is also a risk of small lumps or bumps, called granulomas, forming under the skin. In most cases, these are harmless, will not be visible, and will disperse over time. Where migrated filler material or lumps are visible, you may need further intervention from your practitioner to dissolve the product or break down the tissue lump.

  • Hypersensitivity/allergy. Most medications carry a potential risk of allergic reactions. Allergic reactions have been reported with hyaluronic dermal fillers and lidocaine, such as anaphylaxis (whole body autoimmune response with oral swelling, airways closing, and difficulty breathing), skin itching, skin swelling, hives, redness, and difficulty breathing. These reactions can occur immediately or days to months later. You should contact your practitioner if you feel unwell or believe you have had an allergic reaction. In cases of severe allergic reaction (anaphylaxis), you should seek immediate emergency medical care by calling for an ambulance.

  • Autoimmune responses. Very rarely, when the body has a heightened immune response, such as during illness or excessive sun exposure, your immune system may attack dermal filler implantations. This can happen weeks or months following the procedure and can cause facial swelling and discomfort and may require medical intervention from us. Please contact your practitioner, should this occur, as you may require medications to be prescribed.

  • Nerve injury. Nerve injury from needle puncture or dermal filler material may occur rarely. It will most likely be temporary, but it could be permanent. This could result in pain, tingling, burning, loss of sensation and/or weakness of local muscles in the area. 

  • Blood vessel blockage. Hyaluronic acid dermal filler can rarely be accidentally injected into or on top of a blood vessel. This could block the blood vessel and cause damage to local and/or distant tissue, which could result in localised skin tissue necrosis (cell death) or potentially even a heart attack, stroke, or blindness. This is a rare medical emergency; your practitioner is trained to deal with it, but you may also require hospitalisation in extreme cases. 

  • Permanent Injury and scarring. Permanent injury to skin tissue or other organs is rare. However, in extreme cases of a complication, any injury could be permanent or result in permanent scarring.

  • COVID-19 Swelling. Although there is limited evidence and only a very small number of cases, there is a risk of inflammatory reactions and soft tissue swelling in patients who have previously received soft tissue fillers or plan to have treatment after receiving COVID-19 vaccination. This is thought to be similar to the above autoimmune response. Do not undergo soft tissue filler procedures within two weeks of your planned vaccination date or within two weeks of having received it.

  • COVID-19 Complication Management. Do not attend treatment if you have symptoms consistent with COVID-19 or are suffering from ongoing symptoms from a previous infection. If you develop any reactions following your treatment, it is imperative you contact your aesthetic healthcare practitioner as soon as possible. If you develop any reactions following your treatment, you may require medication to manage the complication. This may include oral steroid medication, which may lower your immunity to COVID-19, even if you have been vaccinated.

Photographs:

We need to take photos of the treatment area to document the original condition before treatment begins and to monitor results and potential changes throughout the treatment process. These photos will become part of your medical aesthetic treatment record at Lumiere Medispa.

You have the right to refuse consent for these photographs. However, please be aware that without this consent, we will not be able to treat you for medico-legal reasons.

If we wish to use your photos for any other purpose, we will always seek separate written consent from you. You have the right to refuse this additional use of your photos, and it is not mandatory to consent to any other photo usage to receive treatment.

Informed Consent:

This consent form is not meant to include all possible risks associated with a hyaluronic acid dermal filler treatment, as there are both known and unknown side effects and complications associated with any medical treatment. We have written this consent form to ensure you are fully informed of the procedure, the reasons why you may not be able to receive treatment and the known risks of a hyaluronic acid dermal filler treatment.

By signing this consent form, you acknowledge and confirm the following:

Risks and complications

You have discussed the potential risks and benefits of a hyaluronic acid dermal filler treatment with your practitioner, and all of your questions have been answered to your satisfaction. 

You understand that medical attention may be required to resolve any complications associated with your treatment. In most cases, except those in an emergency, you should contact your practitioner for advice/treatment. 

Medical History

To the best of your knowledge, you have provided the details of your past medical history and will inform your practitioner if this changes before any future treatments. 

You understand that withholding aspects of your medical history could lead to serious physical and mental harm.

Contraindications & Cautions 

You are not pregnant or possibly pregnant, lactating or nursing, and you will inform your practitioner if this changes before any future treatments.

Fees & Charges 

You understand and agree that all services rendered will be charged directly to you, and you are personally responsible for payment. 

You further agree, in the event of non-payment, to bear the cost of collection, court costs and reasonable legal fees, should they be required. 

Refunds

Fees charged for treatment are for the delivery of a treatment and the accompanying service, which is inclusive of the following; 

-Consultation and assessment 

-The provision of information and advice 

-The provision of the treatment itself, as described above

-Follow-up appointments and aftercare advice and support as appropriate

Whilst we undertake to provide excellent service, factual, honest, and ethical advice, safe, expert treatment in experienced hands, and the best products, we cannot guarantee your results. We cannot offer refunds if the results achieved fail to meet your expectations. The successful outcome varies by degree, and how long these effects last varies from one individual to another and cannot be guaranteed. 

You understand that whilst you have been advised of a probable result, this should not be interpreted as a guarantee.  

You will contact your practitioner if you are unsatisfied with your treatment outcomes.

Aftercare

You have verbally discussed the aftercare required following a hyaluronic acid dermal filler treatment, and you have been informed that you will also receive this via email. You understand the importance of following the post-treatment advice and agree to follow it. 

You understand that failure to follow this advice could lead to serious physical and mental harm.

Photograph Use Consent:

You understand that receiving treatment at Lumiere Medispa requires photographs to be taken of the treatment area. These photographs may be taken before, during, and after each treatment and will form part of your legal medical record at Lumiere Medispa. By signing below, you freely give your consent for your photos to be used solely for this medico-legal purpose. If we wish to use your photos for any other purpose, we will always seek separate written consent from you, and you have the right to refuse.

Valid Consent

By signing below, you acknowledge that you have read and understood this consent form and have had the opportunity to discuss any questions you have with your practitioner to your satisfaction. You consent to receive a hyaluronic acid dermal filler treatment under the terms of this consent form and understand that you have the right not to consent to this treatment and that your consent is voluntary.