This is an informed consent document that has been prepared to help inform you concerning filler injections, its risks and alternative treatment/s.

It is important that you read this information carefully and completely.


Filler is an injectable hyaluronic acid gel. It is injected into facial tissue to smooth wrinkles and folds. 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 in water and act as a cushioning agent. Filler is injected into areas of facial tissue where moderate to severe facial wrinkles and folds occur.


Every procedure involves a certain amount of risk, and it is important that you understand the risks involved. An individual’s choice to undergo a procedure is based on the comparison of the risk to potential benefit. Although most patients do not experience these complications, you should discuss each of them with your medical aesthetic physician to make sure you understand the risks, potential complications and consequences of filler injections.

  • Severe allergies marked by a history of anaphylaxis.
  • Patients with a history of allergies to gram-positive bacterial proteins.
  • Patients who are using substances that can prolong bleeding, such as aspirin or ibuprofen, as with any injection, may experience increased bruising or bleeding at injection site. You should inform your physician before treatment if you are using these types of substances.
  • Infection is unusual. Should an infection occur, additional treatment including antibiotics may be necessary?
  • In rare cases, local allergies to topical preparations have been reported.
  • Fillers should be used with caution with patients on immunosuppressive therapy, used to decrease the body’s immune response as there may be an increased risk of infection.
  • There is the possibility of an unsatisfactory result after the procedure.
  • Within the first 24 hours you should avoid strenuous exercise, extensive sun or heat exposure and alcoholic beverages. Exposure to any of the above may cause temporary redness, swelling, and/or itching at the injection sites.

Additional treatment if necessary

In some situations, it may not be possible to achieve optimal results with a single procedure.  Should complications occur other treatments may be necessary. Even though risks and complications occur infrequently, the risks sighted are the ones that particularly associated with anti-wrinkle injections.

The practice of medicine is not an exact science. Although satisfactory results are expected, there cannot be any guarantee or warranty expressed or implied on the results that may be obtained.


Informed-consent documents are used to communicate information about the proposed treatments of a condition along with discloser of risk and alternative forms of treatment(s). The informed consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances.

However, informed-consent documents should not be considered all inclusive in defining other methods of care and risks encountered. Your medical aesthetic physician may provide you with additional or different information which is based on all the facts in your case and the state of medical knowledge.

Informed consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined based on all the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve.

It is important that you read the above information carefully and have all your questions answered before signing this consent.

The information mentioned by me is true and correct. I acknowledge the risks associated with treatment have been explained and all questions asked and answered satisfactory. I confirm that Dr or any of the staff members shall have no liability, vicarious or otherwise, for any loss of damage, harm or injury which I may suffer in consequence of agreeing to accept such treatment.

I have read the foregoing consent for the procedure, understand it, accept these facts, and thereby authorize the doctor to perform the procedure of filler injections.

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