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Informed Consent Form - Dermal Fillers

Hyaluronic Acid Dermal Filler Treatment

This treatment uses dermal filler which is a hyaluronic acid for the purpose of injection into the skin to correct facial lines, wrinkles and folds, for lip enhancement and for shaping the facial contours:


  • The dermal filler conforms to the current safety standards in the UK.

  • It is a non-permanent procedure and a repeat procedure may be required to maintain the results. In training, we normally use a mild filler type.

  • The methods of use and indications for this product have been explained to me by my practitioner and I have had the opportunity to have all questions answered to my satisfaction

The areas we propose to treat are : -

I have been specifically informed about the following :-


  • After the injection some common injection-related reactions might occur, such as swelling, bruising, redness, pain, itching, dis-coloration and tenderness at the site. They typically resolve spontaneously within 7 days after injection into the skin.

  • Other types of reactions are very rare, a small number of people have experienced localised reactions thought to be of hypersensitivity in nature. These have usually consisted of swelling at the injection site, sometimes affecting the surrounding tissues. Redness, tenderness and rarelyacne-like formations have also been reported.

  • These reactions have either started a few days after injection or after a delay of 2-4 weeks and have been described as mild to moderate and self-limiting. To limit these reactions, we require that you keep the area clean and makeup free for 24 hours post treatment.

  • I have read and fully understand this agreement and all the information detailed above. | understand the procedure and accept the risk. All my questions have been answered to my satisfaction and I consent to the terms of this agreement.

  • I do not hold FaceHarmoni responsible for any of my conditions not disclosed at the time of the procedure, which may be affected by the treatment performed today.

  • I consent to be photographed before, during and after treatment. I understand that these photographs will remain the property of professional practice and will not be used for marketing purposes without my explicit permission.

  • I understand that I should contact my practitioner directly and immediately if I have any concern relating to the treatment. Each treatment is charged for individually, and according to the amount of product that is used or depending upon the price of an area. This will be agreed prior to treatment.

  • I hereby authorise Yufei Shi (experienced and qualified Aesthetic practitioner).

  • I understand that FaceHarmoni will not issue a refund for any reason once the treatment is completed unless required by statutory law.

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