Hyaluronidase informed consent form template

November 11, 2026 · 6 min read

Editorial illustration about a hyaluronidase informed consent form

Hyaluronidase is the enzyme used to break down injected hyaluronic acid. It comes into play when the filler is excessive, uneven, visible, or when there is a complication. The informed consent form records that the patient understood why it will be used, what can happen, and that the result is not guaranteed.

The template below is generic, with no brand, no dose and no dilution. To understand the enzyme, read hyaluronidase in the clinic, the glossary entry on hyaluronidase and hyaluronidase and Anvisa (Brazil's health regulatory agency).

When should you use this template?

Before any planned use of the enzyme: correcting excess, irregularity or a result the patient wants to reverse. In an acute complication, such as a suspected vascular occlusion, the patient needs immediate care. Record verbal consent in the patient chart and complete the form as soon as possible, following your attorney's guidance. For the reasoning in these situations, see lip vascular occlusion and nasal vascular occlusion.

How do you adapt it?

State the purpose (planned correction or treatment of a complication) and the areas involved, without getting into dose.
Record the decision on sensitivity testing: whether it was done and why, or why not. Read hyaluronidase: allergy and testing.
Explain that repeating may be necessary and that the result varies. See does hyaluronidase remove all the filler?.
State the window of action: the effect is usually noticed within hours to days, with variation. See hyaluronidase: how long does it take to work.
Record the product, manufacturer, registration and lot used, according to your routine, and stick the label in the patient chart.
Review with an attorney and with your professional board's rules on the use of medications.

What must never be missing?

Item	Reason
Purpose and area	The patient knows why and where
What the enzyme does and that the effect is not guaranteed	No promises
Common effects: pain, swelling, redness, bruising	Expected to varying degrees
Possible loss of volume greater or smaller than desired	Effect on the hyaluronic acid in the area
Allergic reaction (rare) and management	Safety
Possibility of repeating the procedure	Aligns cost and time
Alternatives, including watching and waiting	Free consent
Decision on sensitivity testing	Records the reasoning
Contact, follow-up and signatures	Continuity of care

Hyaluronidase informed consent form template

Template

INFORMED CONSENT FORM: HYALURONIDASE

Patient: ________

Date of birth: ________

CPF (Brazilian taxpayer ID): ________

Responsible professional: ________

Professional board and registration number: ________

Clinic: ________

1. What it is and what it is for

Hyaluronidase is an enzyme that breaks down hyaluronic acid. In my case, it will be used to: ( ) correct excess, irregularity or an unwanted result from a previous filler ( ) treat a complication related to filler ( ) other purpose: ________. Area(s): ________.

2. How it is done

The enzyme is given by injection in the area, in the amount and at the points defined by the professional according to my assessment. There may be discomfort during the injection.

3. What I can expect

I understand that the enzyme acts on hyaluronic acid and that the result varies: it may reduce the filler partially or extensively, and the injection may need to be repeated, which may have a cost. I understand that it is not possible to predict precisely how much will be reduced, and that the enzyme may also affect the natural hyaluronic acid in the area and fillers from other times in the same place. I also know that the result is not guaranteed.

4. Common effects

The following may occur, usually temporarily: pain or burning, redness, swelling, bruising (hematomas), a feeling of local pressure and temporary asymmetry. There may also be a loss of volume greater or smaller than expected, with a need for new filler later, at the professional's discretion and when indicated.

5. Less common and rare risks

The following may occur less commonly: uneven results between the sides, irregularities, infection at the site and local allergic reaction. In rare cases, there may be a stronger allergic reaction that requires immediate care. If the reason for the injection is a complication (such as compromised circulation), I understand that using the enzyme does not guarantee the problem will be reversed and that other measures may be needed, including referral to an emergency service.

6. Sensitivity test

The professional assessed the need for a sensitivity test before the injection. Decision recorded: ( ) test performed, with result ________ ( ) test not performed, for the reason ________.

7. Information I provided

I have truthfully reported my history of allergies (including bee stings or other products), medication use, illnesses, pregnancy or breastfeeding, infection or wound in the area, and previous procedures. I know that omitting information increases the risks.

8. Alternatives

Alternatives were presented to me, including watching and waiting to see how things progress, other care, and the option of not having the procedure. I freely choose this option.

9. Care and contact

I received written instructions on care and warning signs (severe pain, change in skin color, blisters, change in vision, shortness of breath or rapid swelling of the face), which require immediate contact: ________. Planned follow-up: ________.

10. No guarantee of results

I understand that the professional cannot guarantee a specific result and that the outcome depends on individual factors.

11. My data

I authorize the processing of my personal and health data for my care and for the patient chart, confidentially, in accordance with Brazil's General Data Protection Law (LGPD).

12. Statement

I have read this form, or it was read to me. I was able to ask questions and they were answered. I understood the information and I choose to have the procedure of my own free will. I know I may withdraw at any time before the injection.

Place and date: ________

Signature of the patient or legal guardian: ________

Name and relationship of the legal guardian, if any: ________

Signature of the professional: ________

Witness (optional): ________

Does the form change if the enzyme is used in an emergency?

The format changes, not the duty to inform. In an emergency, the priority is to treat; consent can be verbal and recorded right after, with the signature completed later. Keep the supplies ready and rehearsed, as in the emergency checklist and the clinic emergency kit. To recall the basis of consent, see informed consent.

Frequently asked questions

What is injectable hyaluronidase for?

It is an enzyme that breaks down hyaluronic acid. In aesthetics, the professional uses it to reduce or remove hyaluronic acid filler that is excessive, misplaced or involved in a complication, at their discretion and based on the assessment of the case.

Does hyaluronidase require an informed consent form?

Whenever possible, yes, as with any procedure. In an emergency (such as a suspected vascular complication), care should not wait for the paperwork: record verbal consent and complete the form afterward, following the guidance of your attorney and your professional board.

Do I need an allergy test before hyaluronidase?

That is the professional's decision, based on the patient's assessment, the product and the urgency. The form should record what was decided and why. See the article on hyaluronidase allergy and testing for the reasoning.

Terms mentioned

Hyaluronidase Hyaluronic acid Informed consent in orofacial harmonization Vascular occlusion in filler Swelling after harmonization Hematoma After Filler Hypersensitivity Reaction to Fillers and Toxin Patient record in facial harmonization