Consent for Treatment with Hyaluronidase
Hyaluronic acid (HA) fillers are sterile gels consisting of non-animal stabilized hyaluronic acid for
injection into the skin to correct facial lines, wrinkles and folds, for lip enhancement and for shaping
Occasionally these fillers need to be dissolved when the aesthetic treatment has not produced
the desired outcome or there is a possibility of vascular occlusion or impending necrosis (tissue death)
which could lead to compromise of healthy tissue.
Hyaluronidase is an enzyme which breaks down hyaluronic acid fillers, but it can also break
down naturally occurring hyaluronic acid present in the body, the results can be unpredictable. I
understand that there will be loss of volume and there can be some skin laxity which in itself may not
provide a good aesthetic result. Although some of the effects can be immediate, I understand it can take
up to 24-48 hours for results to be seen and the treatment may need to be repeated.
What are the possible side effects of hyaluronidase?
Get emergency medical help if you have any of these signs of an allergic reaction: hives;
difficulty breathing; swelling of your face, lips, tongue, or throat. Less serious side effects may include
pain, itching, redness, or swelling where the medication was injected. This is not a complete list of side
effects and others may occur.
I have disclosed all my medical history and medications to my provider. I am currently not taking any
of the following medications.
1) Furosemide (Lasix)
2) Phenytoin (Dilantin)
3) A sedative or anxiety medication (such as Valium, Xanax)
4) Aspirin or salicylates
5) Cortisone or ACTH (Corticotropin)
7) An antihistamine (such as a cold or allergy medicine)
The use of and the indications for the administration of hyaluronidase have been explained to
me by my practitioner and I have had the opportunity to have all questions answered to my satisfaction.
After the treatment some other common injection-related reactions might occur. These reaction may
include redness, swelling, pain, itching, bruising and tenderness at the injection site. They have generally
been described as mild to moderate and typically resolve spontaneously a few days after injection.
I acknowledge that I will have to remain at the clinic for thirty minutes after the procedure so
that I can be observed by the practitioner and that I may need to return to the clinic in 1-2 weeks after
treatment to assess if further hyaluronidase is to be administered.
I have answered the questions regarding my medical history to the best of my knowledge. I have
also received the aftercare information and its contents have been explained to me and I will follow the
I consent to the administration of hyaluronidase. I am satisfied with the explanation. If I have
any questions or problems after treatment I will call Dr. Happe Medical Aesthetics, LLC. I have been
provided with their contact information.