Dermal filler consent form template (UK)

This template is for UK aesthetics practitioners administering hyaluronic acid dermal fillers to the face. Filler consent carries more weight than almost any other document in your clinic, because the risk profile includes vascular occlusion, a rare but serious complication that every competent consent process must disclose in plain language. A defensible form is informed (the patient saw the serious risks in writing, not just the bruising), specific (the product and areas are named), signed by patient and practitioner, versioned (you can prove which wording was signed on that date) and retrievable on demand.

Why each section exists

Insurers reviewing a filler claim look first at whether vascular occlusion, skin necrosis and visual impairment were disclosed before treatment. Burying them in a paragraph of soft language is the most common failure. This template itemises them so the patient acknowledges each one individually.

The previous-filler disclosure exists because layering a new product over unknown existing filler changes the risk picture, and because a patient who withheld that history has signed a statement saying otherwise. The hyaluronidase note matters for two reasons: it is part of honest risk communication (problems can usually be managed by dissolving the filler), and it establishes upfront that dissolution is itself a procedure with its own consent and its own risks.

England is moving towards a licensing scheme for non-surgical cosmetic procedures, and the consistent signal from consultations is that written, auditable consent and complete treatment records will be baseline expectations rather than good practice. Versioned consent plus a treatment record with batch numbers is the standard worth building now.

The template

Patient details

Full name: ___________________________

Date of birth: ___________________________

Phone: ___________________________

Email: ___________________________

Address: ___________________________

Treatment details

Product and brand: ___________________________

Areas to be treated: ___________________________

Approximate volume planned (ml): ___________________________

Date of treatment: ___________________________

About this treatment

Hyaluronic acid dermal fillers are injectable gels used to restore volume, soften folds and refine facial contours. Results are visible immediately, settle over around 2 weeks, and typically last 6 to 18 months depending on the product, the area treated and the individual. No specific outcome can be guaranteed.

Previous treatment disclosure

Have you had dermal filler in any area before, with this clinic or elsewhere? Yes / No

If yes, please give the area, approximate date and product if known:

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• I confirm I have disclosed all previous filler treatments and any permanent or semi-permanent implants or filler to the best of my knowledge.

Exclusions and screening

• I am not pregnant and not breastfeeding
• I do not have an active skin infection, cold sore or inflammation at the treatment site
• I am not allergic to hyaluronic acid fillers or lidocaine
• I have told my practitioner if I have ever had a serious reaction to bee or wasp stings (this matters if filler ever needs to be dissolved with hyaluronidase; it does not necessarily rule out treatment)
• I have disclosed all medication I take, including blood-thinning medicines and supplements
• I have disclosed any autoimmune condition, keloid scarring or abnormal healing

Risk acknowledgement

I understand and accept the following recognised risks of dermal filler treatment:

• Bruising, redness, swelling and tenderness at the injection sites
• Lumps, nodules or irregularity, which may need massage, review or dissolution
• Asymmetry of result, which may require adjustment
• Infection at the injection site
• Migration of product from the treated area over time
• Delayed-onset swelling or inflammatory reaction, sometimes weeks or months later

Serious risk: vascular occlusion

• I understand that filler can rarely be injected into or compress a blood vessel (vascular occlusion). This can cause skin damage and, if untreated, skin necrosis (tissue death and scarring). Extremely rarely, occlusion of vessels supplying the eye can cause visual impairment or blindness.
• I understand the warning signs (unusual or worsening pain, white or dusky discolouration of the skin, blistering, any change to my vision) and that I must contact the clinic immediately if they occur, at any time after treatment.
• I understand that hyaluronic acid filler can usually be dissolved with hyaluronidase if a complication occurs or the result is unsatisfactory, that hyaluronidase is itself a prescription treatment with its own risks including allergic reaction, and that it requires separate consent.

Photography

• I consent to clinical photographs being taken before and after treatment for my confidential patient record.
• I additionally consent to my photographs being used for marketing purposes (optional).

Outcome and review

• I understand that results cannot be guaranteed, that swelling can mask the final result for around 2 weeks, and that any review or adjustment is assessed at a follow-up appointment rather than on the day.

Patient declaration

I confirm that I have read and understood the information above, including the serious risks, that I have had the opportunity to ask questions and that they have been answered to my satisfaction. The information I have given is true and complete. I consent to dermal filler treatment as described.

Patient signature: ___________________________

Print name: ___________________________

Date: ___________________________

Practitioner declaration

I confirm that I have explained this procedure to the patient, including its intended benefits and material risks (including vascular occlusion), and any available alternative treatments, and that the patient has had the opportunity to ask questions.

Practitioner signature: ___________________________

Print name and qualification: ___________________________

Date: ___________________________

Using it in practice

Copy the template into your own letterhead, name the actual product you stock, and date the version. Keep superseded versions: if a patient signed the 2025 wording, you need to be able to produce the 2025 wording. Use it alongside a current medical history form, and log the product, batch number and volumes on a treatment record at the time of injection.

AesthetiClinic removes the paper handling entirely: the form goes e-signed to the patient’s phone before the appointment, every wording change is versioned automatically, and the signed document files itself on the patient record. See the features overview.

Send written aftercare with every treatment; our dermal filler aftercare guide is a sound starting point, and the full set of free documents is in the template library.

This template is provided as a starting point for UK aesthetics practice. It is not legal or medical advice. Review the wording with your insurer and, where relevant, your prescriber before use.