Hyaluronidase consent form template (UK)

This template is for UK practitioners using hyaluronidase to dissolve hyaluronic acid dermal filler, whether electively (migration, overfilling, lumps, unwanted product) or as part of complication management. Hyaluronidase is a prescription-only medicine, so prescriber involvement is part of the treatment and part of the consent. A defensible form is informed (the allergy risk is acknowledged in writing, not mentioned in passing), specific (the areas and the reason for dissolving are named), signed by patient and practitioner, versioned and retrievable on demand.

Why each section exists

Allergy leads this form because it leads the risk profile: hyaluronidase carries a recognised risk of allergic reaction, rarely including anaphylaxis, which is why elective dissolving conventionally involves a patch test and why the acknowledgement line for it sits in the template rather than in the conversation only. The over-dissolution section exists because the enzyme does not perfectly distinguish filler from the body’s own hyaluronic acid, and a patient who was told in writing that temporary deflation of surrounding tissue is possible is a very different conversation from one who was not.

The incomplete-dissolving acknowledgement protects both sides of a common scenario: older, layered or cross-linked product can need repeat sessions, and unknown product from another clinic may not be hyaluronic acid at all, in which case hyaluronidase will not touch it. The prescriber section reflects the legal position; recording who prescribed and how they assessed the patient is the difference between a compliant POM pathway and a paper exercise. And as with all consent in this specialty, England’s planned licensing scheme points one way: written, versioned, auditable consent as baseline practice.

The template

Patient details

Full name: ___________________________

Date of birth: ___________________________

Phone: ___________________________

Email: ___________________________

Address: ___________________________

Treatment details

Reason for dissolving (e.g. migration, overfilling, lumps, unwanted result): ___________________________

Areas to be treated: ___________________________

Original filler product and date, if known: ___________________________

Filler placed at this clinic / elsewhere / unknown (circle): ___________________________

Date of treatment: ___________________________

Prescriber name and registration number: ___________________________

About this treatment

Hyaluronidase is an enzyme used to break down and disperse hyaluronic acid dermal filler. It is a prescription-only medicine, prescribed for you following assessment. Change is often visible within hours and the full effect is judged over the following days. Hyaluronidase works on hyaluronic acid fillers only; it has no effect on other filler types, and product of unknown origin may not respond. More than one session may be required.

Patch test (elective dissolving)

• I have received a test dose of hyaluronidase and have been observed for a reaction in line with this clinic’s protocol, and I understand that a clear patch test reduces but does not eliminate the risk of allergic reaction.

Patch test site and date: ___________________________

Result: ___________________________

Exclusions and screening

• I am not pregnant and not breastfeeding
• I do not have an active skin infection or inflammation at the treatment site
• I have no known allergy to hyaluronidase
• I have disclosed any allergy to bee or wasp venom
• I have disclosed all medication I take and my relevant medical history

Risk acknowledgement

I understand and accept the following recognised risks of hyaluronidase treatment:

• Allergic reaction, including rash, itching, swelling and, rarely, anaphylaxis (a severe, potentially life-threatening reaction requiring emergency treatment)
• Dissolving of my body’s own natural hyaluronic acid in the treated area, which can cause temporary deflation, looseness or accentuated lines while natural hyaluronic acid replenishes
• Bruising, redness, swelling and tenderness at the injection sites
• Infection at the injection site
• Incomplete dissolving, which may require one or more repeat sessions
• An unpredictable final appearance, since the amount, age and type of existing filler cannot always be known, particularly where it was placed elsewhere
• I understand that if I wish to have new filler after dissolving, a settling period will be recommended before re-treatment

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).

Patient declaration

I confirm that I have read and understood the information above, including the risk of allergic reaction, 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 hyaluronidase 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 allergic reaction and the possibility of incomplete or over-dissolving), and any available alternatives including not treating, and that the patient has had the opportunity to ask questions. A prescriber has assessed the patient and prescribed this treatment.

Practitioner signature: ___________________________

Print name and qualification: ___________________________

Date: ___________________________

Using it in practice

Copy the template onto your own letterhead, adapt the patch test wording to the protocol your prescriber has agreed, and date the version; keep superseded versions so you can always produce the wording a patient actually signed. For emergency use in a suspected vascular occlusion, your written emergency protocol governs and consent is handled in line with it; this form is built for the elective pathway. Use it alongside a current medical history form, record the product, batch number, dilution and volumes on a treatment record, and read our hyaluronidase guide for the protocol around the form. The full set of free documents is in the template library.

AesthetiClinic sends this form e-signed to the patient’s phone before the appointment, versions every wording change automatically and files the signed document on the patient record alongside the photographs and batch numbers. See the features overview.

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.