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Filler Consent Form


Healthspan Medical PTY LTD


I confirm I have been informed that:

The filler is injected into the skin to help correct wrinkles, folds and lines of the face and skin, or for

lip enhancement. You should be aware that the combination of fillers with certain drugs (e.g., beta-
blockers) that reduce or inhibit the metabolism of the liver is inadvisable. Ask your doctor for

guidance. You should be made aware that this product contains 0.3% of lidocaine (lidocaine is a local
anaesthetic, i.e., it alleviates feelings of pain), that may produce a positive result in anti-doping tests.

Due to the use of a needle, there is likely to be some bleeding at the injection site. Reactions giving
rise to, for example, redness and swelling may occur after the injection, and this may be associated
with stinging, itching or discomfort upon pressure at the injection site. This reaction may last for
several days. Rarely discoloration of the injection site, necrosis (tissue death), abscess formation,
granulomas (small bumps), hypersensitivity and hematomas (excessive bruising) have been
reported. Indurations (hardening) or nodules (bumps) may develop at the injection site. Rare but
serious adverse events associated with intravascular injection of dermal fillers in the face and tissue
compression have been reported and include temporary or permanent vision impairment. In
addition, abscesses, granuloma and immediate or delayed hypersensitivity after hyaluronic acid
and/or lidocaine injections have also been reported.

If any of these symptoms persist for more than one week, or if any other side effects develop please
report them to your medical doctor as soon as possible so that they can advise you on the best
course of treatment. Whilst rare, such side-effects and their treatment may last for several months.
The aesthetic effects of dermal filler products can last from 9 to 24 months. The aesthetic effect of a
skin booster skin quality injectable, can last up to 9 months. Results will vary depending on the
condition of the skin, area treated, amount of product injected, injection technique and lifestyle
factors such as sun exposure and smoking.
The average life of treatment in the lips is less than in other areas because of the increased activity
of the lip area. A touch-up procedure may be required 1-3 weeks after the first injection and helps to
optimize the results and maximize the duration of the results.
After treatment, please avoid extreme facial expressions, alcohol consumption and applying make
up for 12 hours. Please avoid extreme sun exposure, UV light, freezing temperatures and saunas for
2 weeks after treatment.

(Before treatment)
One week prior to your filler injection, we advise you to avoid using alcohol, garlic and/or aspirin, or
any other non-steroidal anti-inflammatory medicines for pain, swelling and/or fever, such as

medicines containing diclofenac, mefenamic acid, indomethacin or ibuprofen - ask your doctor or
pharmacist whether your medication includes any of these ingredients. Following these instructions
will reduce the risk of bruising or bleeding at the point of injection.
If this is your first visit, you will need to provide your medical doctor with information on your
medical history and any current problems, as well as details of any allergies you have or medications
you are taking. There is no need for an allergy test, unless your medical practitioner feels it’s

(After treatment)
Because the filler injectable gel is a non-surgical treatment, there is minimal recovery time. For the
first 24 hours following treatment, you should avoid strenuous exercise, excessive sun or heat
exposure, and alcoholic beverages, in order to help minimize the risk of temporary redness, swelling
and/ or itching.
No treatment can halt the ageing process; you will require top-ups if you want to maintain the effect
so ask your medical doctor when he/she would recommend rescheduling another appointment.

Treatment may be refused by your HCP if it is not considered in your best interest to proceed.

I understand that I can withdraw this consent at any stage prior to the commencement of treatment,
and that any subsequent decision relating to refusal of continued treatment, including top-ups, will
have an effect on the achievement of the treatment. I therefore consent to receiving the described
treatment by my medical doctor.

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