Lip filler consent form template (UK)

This template is for UK aesthetics practitioners administering hyaluronic acid filler to the lips and perioral area. Lip filler deserves its own consent form rather than a generic filler sheet: the lips swell more than any other treated area, cold sore reactivation is a real and common issue, and the labial arteries make the vascular occlusion conversation unavoidable. A defensible consent form is informed (the serious risks are in writing), specific (lips, this product, this volume), signed by both parties, versioned and retrievable when an insurer or solicitor asks for it.

Why each section exists

The risk acknowledgement is itemised because that is what holds up under challenge. A patient who has ticked “migration” and “lumps” individually is in a very different position from one who signed beneath a single sentence about “possible side effects”. The cold sore question appears in screening because filler treatment can reactivate the herpes simplex virus, and a practitioner who asked, recorded the answer and offered prophylaxis where appropriate has a clean record.

The vascular occlusion section is the heart of the document. Insurers expect to see that necrosis and the very rare risk of visual impairment were disclosed in plain language before lip treatment, not mentioned afterwards. The hyaluronidase note completes the picture: it tells the patient that most problems are manageable, while establishing that dissolution is a separate procedure with separate consent.

England’s planned licensing scheme for non-surgical cosmetic procedures points firmly towards auditable written consent and complete records as the regulatory baseline. Clinics that can already produce a dated, versioned, signed form for every lip treatment will not need to change anything when the scheme lands.

The template

Patient details

Full name: ___________________________

Date of birth: ___________________________

Phone: ___________________________

Email: ___________________________

Address: ___________________________

Treatment details

Product and brand: ___________________________

Area: lips / perioral lines / vermillion border (circle or state): ___________________________

Approximate volume planned (ml): ___________________________

Date of treatment: ___________________________

About this treatment

Hyaluronic acid lip filler adds volume, definition and hydration to the lips. Swelling is expected and can be significant for the first 2 to 3 days; the settled result is usually visible at around 2 weeks. Results typically last 6 to 12 months. No specific outcome, shape or size can be guaranteed.

Previous treatment disclosure

Have you had lip filler before, with this clinic or elsewhere? Yes / No

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

---

• I confirm I have disclosed all previous lip treatments, including any filler I believe has not fully dissolved.

Exclusions and screening

• I am not pregnant and not breastfeeding
• I do not currently have a cold sore, and I have told my practitioner if I have a history of cold sores (filler treatment can reactivate them)
• I do not have an active skin infection or inflammation at or near the treatment site
• I am not allergic to hyaluronic acid fillers or lidocaine
• I have no dental work planned within 4 weeks before or after this treatment
• I have disclosed all medication I take, including blood-thinning medicines and supplements

Risk acknowledgement

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

• Bruising, tenderness and significant swelling, typically worst in the first 72 hours
• Lumps, firmness or irregularity, which may need massage, review or dissolution
• Asymmetry of result, which may require adjustment
• Infection at the injection site
• Migration of product beyond the lip border over time
• Reactivation of cold sores in patients with a history of herpes simplex

Serious risk: vascular occlusion

• I understand that filler can rarely be injected into or compress a blood vessel (vascular occlusion). In the lips this can damage the skin and, if untreated, cause skin necrosis (tissue death and scarring). Extremely rarely, occlusion affecting vessels that supply the eye can cause visual impairment or blindness.
• I understand the warning signs (severe or worsening pain, white or dusky discolouration, blistering, any change to my vision) and that I must contact the clinic immediately if they occur, including out of hours.
• I understand that hyaluronic acid filler can usually be dissolved with hyaluronidase if a complication occurs or I am unhappy with the result, that hyaluronidase carries 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 will exaggerate the initial appearance, and that the result is assessed at a review appointment at around 2 weeks rather than on the day.

Patient declaration

I confirm that I have read and understood the information above, including the serious risks. I have had the opportunity to ask questions and they have been answered to my satisfaction. The information I have given is true and complete. I consent to lip 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 this into your own document, add your clinic details and the product you actually use, and date the version so you can always match a signature to the exact wording signed. File it with the patient’s medical history form, and record product, batch number and volume per site on a treatment record at the time of injection.

AesthetiClinic does this without the printing and scanning: the form is sent e-signed to the patient’s phone before the appointment, the wording is versioned every time you edit it, and the signed copy files itself on the record. Details on the features page.

Give written aftercare with every lip treatment; start from our lip filler aftercare guide, and find the rest of the free documents 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.