Lip Filler

Beauty Creation

Lip Filler Form

    Botox/Dermal Fillers Consent Form


    Health Questionnaire



















    in the area to be treated:




    Common Side Effects Associated with the injection

    • Pain or stinging sensation when the injectIon is performed
    • Localised swelling, redness and or tenderness
    • Bleeding at the sites of injection
    • Bruing. Rarely bruising may be severe and may persist for several weeks
    • Numbness or itching of the area following injection

    Common side effects are expected to resolve spontaneously within the first few days of treatment. Whilst not expected, it is possible that reactions described may persist for longer and may inhibit your confidence to attend work or social events. You are advised to schedule treatrnents with this in mind, allowing time for common reactions such as bruising and swelling, to settle.

    Uncommon Side Effects

    • Infecton
    • Inflammation
    • Skin discolouration (which may occur within a few days or weeks to months following treatment)
    • Allergic or sensitivity reaction, which may be local (redness, itching or rash at the site of treatment) or may be severe requiring hospital treatment
    • Abscess formation
    • A foreign body reaction, known as 'granuloma' presenting as lumps or nodules
    • The blood supply to the skin may be interrupted by swelling or inadvertent injection into a vessel, causing pain, skin damage and possible scarring. Correction is expected to last for a period of 6-12 months. The successful outcome varies by degree and how long it lasts vanries from one individual to another and cannot be guaranteed.

    I understand if I suffer any adverse reactions that are not expected, or concern me, I must contact the clinic. An appointment will be made for me to be seen. The clinic cannot take responsibility for complications or results that have not been reported, assessed, documented and managed in a timely fashion.

    I confirm that the medical health history form has been completed truthfully and I am fully aware that withholding medical infomtation, including history of previous treatment, may be detrimental to the safe and optimal outcome of any treatment administered. If there are any changes in my medical history, I must inform the practitioner.

    I confirm that I have been provided with verbal and written information about this treatment which includes aftercare and follow up advice.

    I agree to follow the aftercare advice and understand this reduces risk of adverse reactions and helps ensure optimum results.

    I understand informatton about me will be treated as confidential and access to it restricted in accordance with the Data Protection Act, unless specific permissions given.

    I consent to photographs being taken for my personal record only and will not be published unless specific and further consent from me is granted. I accept no fee is payable to me or any other person in respect of the material either now or at any time in the future.