Dermal Filler Consent

Elite Clinique | Consent Form

This consent form is specific to the administration of hyaluronic acid (HA) dermal filler injections. This form must be completed in addition to the General Treatment Consent form.

Dermal fillers are injectable gels used to restore volume loss, enhance facial contours, smooth lines and folds, and improve skin hydration. We use CE-marked, premium-grade hyaluronic acid-based dermal fillers. Hyaluronic acid is a substance naturally found in the body, and HA fillers are biocompatible, biodegradable, and reversible using the enzyme hyaluronidase.

COOLING-OFF PERIOD: In accordance with JCCP and CPSA guidance, a minimum 48-hour cooling-off period must elapse between your initial consultation and this treatment. If you are attending for a repeat treatment and have had a recent consultation, this requirement may be waived at your practitioner's discretion.

ALTERNATIVES: Alternative treatments may include botulinum toxin, fat transfer, thread lifts, skin resurfacing treatments, topical treatments, or no treatment. Your practitioner will have discussed any alternatives relevant to your presentation.

VASCULAR OCCLUSION — IMPORTANT SAFETY INFORMATION: In rare cases, dermal filler can inadvertently be injected into or compress a blood vessel (vascular occlusion). This is a medical emergency that can result in tissue death (necrosis), scarring, or, in extremely rare cases, vision impairment or blindness if filler affects the ophthalmic artery. Our practitioners are trained in the recognition and emergency management of vascular occlusion and carry hyaluronidase on-site at all times.

Risks & Side Effects

Very Common

Affects more than 1 in 10 people

Swelling and redness at injection sites (may last 2-7 days, particularly for lip treatments)

Common

Affects up to 1 in 10 people

Bruising at and around injection sites (may last 7-14 days)
Tenderness, firmness, or lumpiness at the treatment site (usually settles within 2 weeks)
Temporary numbness or altered sensation

Uncommon

Affects up to 1 in 100 people

Asymmetry requiring touch-up or adjustment at review appointment
Palpable nodule or lump formation that may require treatment or dissolution
Migration of filler from the intended treatment area
Reactivation of herpes simplex (cold sores) — particularly with lip treatments

Rare

Affects fewer than 1 in 1,000 people

Vascular occlusion (blocked blood vessel) potentially causing tissue necrosis, scarring, or in extremely rare cases, vision impairment or blindness
Delayed hypersensitivity or granulomatous reaction (immune response weeks to months after treatment)
Infection at the injection site, including biofilm formation

Contraindications

Treatment may not be suitable if you:

✕Pregnancy or breastfeeding
✕Active cold sores (herpes simplex), skin infection, or inflammation at or near the treatment site
✕Known allergy or hypersensitivity to hyaluronic acid, lidocaine (if present in the filler), or any product excipient
✕Autoimmune conditions that may predispose to granulomatous reaction
✕Current use of blood-thinning medication (increased bruising risk — discuss with your practitioner)
✕History of anaphylaxis to any dermal filler product
✕Active dental infection or recent dental procedure within 2 weeks (for treatments in the lower face)
✕Permanent non-resorbable filler previously placed in the treatment area

Patient Declaration

By signing this consent form, I confirm that:

1I confirm that at least 48 hours have elapsed since my initial consultation for this treatment, or I am attending for a repeat treatment following a recent consultation.
2I understand that hyaluronic acid dermal fillers provide temporary results, typically lasting 6-18 months depending on the product used, the area treated, and individual factors.
3I understand that the filler can be dissolved using hyaluronidase if necessary, and that dissolution may be required in the event of a complication or unsatisfactory result.
4I have been fully informed about the rare but serious risk of vascular occlusion and I understand the warning signs: unusual and worsening pain, blanching (white skin), dusky discolouration, or any changes to my vision. I will contact the clinic immediately if I experience any of these symptoms.
5I will avoid touching, pressing, or massaging the treated area for 24 hours unless advised otherwise by my practitioner.
6I will avoid extreme heat (saunas, steam rooms, hot baths), extreme cold, strenuous exercise, and excessive alcohol for 48 hours following treatment.
7I understand that swelling and bruising are expected and that the final result should be assessed no earlier than 2 weeks post-treatment.
8I will attend my review appointment (if scheduled) to allow my practitioner to assess the treatment outcome.
9I understand that additional product or sessions may be recommended to achieve the desired result, and that this may incur additional cost.
10I understand that no guarantee of a specific outcome is given or implied, and that individual responses to dermal fillers vary.

Note: This is an informational copy of our consent form. The formal consent process takes place in person with your practitioner before treatment.