Consent Form

Juvederm Ultra and Uma Jeunesse injectable fillers are a clear hyaluronic acid gel that is injected into facial tissues to smooth wrinkles and folds. Hyaluronic acid is a naturally occurring substance found in the body that delivers nutrients, hydrates the skin, acts as a cushioning agent, and provides scaffolding to lift any folds. Dermal fillers may also be used to treat facial atrophy (Loss of fat), for facial sculpturing, and skin enhancement. A dermal filler injectable gel temporarily adds volume to facial tissue and restores a smoother appearance to the face.

How long does a HA dermal filler last?

You should see an immediate improvement in the treated areas on the day. Depending on the area treated results may last 6 months or more. Some of our products may last up to 18months.

What are the possible side effects?


Most side effects are mild or moderate and usually last less than 7 days. Persistence of these symptoms for up to two weeks is usually noting to worry about. The most common side effects include temporary injection site reactions such as redness, pain/ tenderness, firmness, swelling, lumps/ bumps, bruising, itching, and discoloration. Other rare risks include, but are not limited to:

  • Overcorrection/ under correction & facial asymmetry

  • Unpredictable persistence of filler, either shorter or longer than expected.

  • Prolonged discoloration of the skin

  • Prolonged or severe swelling

  • Reactivation of cold sores

  • Infection

  • Scaring

  • Ulceration

  • Granulomas or firm nodules

  • Benign tumor formation (keratoacanthomas)

  • Allergic or anaphylactic reaction

  • Blindness


A remote and extremely rare risk is that of filler injection into a blood vessel, leading to blockage of the vessel. This could result in reduced blood flow to an area of tissue, leading to tissue damage and tissue death (neurosis), which could be seen as skin breakdown, ulceration and scar formation. Blood vessel blockage near the eye can result in blindness.


Is there anyone that cannot be treated?

Dermal fillers should no be used in patients who have severe allergies marked by a history of anaphylaxis, a history of severe allergies, or patients with a history of a compromised immune system. The doctor will ask you about your medical history to determine if you are an appropriate candidate for treatment.


What should I expect with HA dermal filler treatments?

The doctor will go over a list of pre and post treatment procedures with you. If you are taking aspirin or ibuprofen you may experience increased bruising or bleeding at the injection site. HA dermal fillers should be used with caution in patients on immunosuppressive therapy as there may be an increased risk of infection, swelling and adverse events. The safety of dermal fillers has not been established in breast-feeding females, during pregnancy, or in patients under the age of 18.


What are post treatments procedures?

For the first 24 hours following treatment, you should avoid strenuous exercise, excessive sun or heat, and consumption of alcoholic beverages. This minimizes the risk of temporary redness, swelling, and/ or itching at the treatment sites. These temporary side effects generally resolve themselves within one week. An ice pack can be applied to the site if you experience swelling. You may apply make-up as usual after 24 hours.

The LSFA is a training school for doctor’s dentists and surgeons to learn dermal filler training in a safe and supported environment. Your procedure today will be carried out by one of the trained delegates under close supervision.

By signing below, I acknowledge that I have fully read the information and consent form and that I have discussed the risk and benefits of dermal fillers with my physician. I understand the information and I consent to dermal filler cosmetic treatment. Photographs may also be used for teaching or educational purposes or for patient information.


I hereby confirm that I understand the above and am happy to continue with treatment. I consent to pre and post treatment photography for medical record purposes. Please tick if you DO NOT consent to your photographs being used for teaching and marketing purpose.

Please select the box below to confirm you have read and understood the above.

Part 2: medical history

Please answer all the below questions.

  1. Are you currently in good health? 


   2. Are you currently under a specific doctors care?


    3. Do you use ANY medication, herbal/ natural supplements or topical creams on a regular basis?


   4. Do you have ANY allergies to medications, food, latex, or other substances?


  5. Have you had any cold sore breakouts (oral herpes) in the past year? 


    6. Do you have a history of keloid scarring


    7. Do you suffer with acne, or have you taken medication for acne in the past 6months?


    8. Do you have ANY current or chronic medial illness, including: myasthenia gravis, amyotrophic lateral sclerosis or          ANY other neuromuscular disorders?


    9.  Do you have an autoimmune disease?


   10. Have you ever had eyelid or facial surgery?


    11. Have you previously received Botox/ dermal filler injections?



    12. Are you, or could you be pregnant?


    13. Are you breast-feeding?


Please sign your name to confirm you accept the above.

Part 3: Doctors Record: (to be completed by practitioner)

Upload images of areas treated