An aesthetic clinic in Scotland must keep a record of consent to treatment in a patient care record written as close to the event as possible. HIS inspectors look for a face-to-face consultation, a signed consent form, the risks discussed, the product, dose and batch, the aftercare given and, in good practice, the time the patient had to consider.
What the rules require
HIS's list of records that every registered independent healthcare service must keep includes a record of consent to treatment, alongside the patient's details, next of kin and GP.1 Regulation 4 of the 2011 regulations requires a patient care record that records, as closely as possible to the time, every consultation with the clinician's name, its outcome, and every treatment with its place, date, time and the responsible clinician.2
At registration every applicant sends a consent policy. HIS points applicants to the Adults with Incapacity (Scotland) Act 2000 and to the consent guidance of their own professional regulator, the GMC, NMC, GPhC or GDC.3
What inspectors read in an aesthetics clinic
In its September 2026 report on an aesthetics clinic in Fife, graded Good in all three key focus areas, HIS reviewed six patient care records. Each had consent to treatment, contact and emergency details, medical history and GP, medicines, a treatment plan and the aftercare advice given. At booking, patients received a medical questionnaire, a consent form and information on the risks. The prescriber assessed suitability face to face, and patient and practitioner signed the consent form on the day of treatment after a full discussion. Doses, batch numbers and expiry dates were recorded with a visual record of injection sites, and where an unlicensed product was used, that was discussed and consent recorded.4
| Field | Why it is there |
|---|---|
| Consultation date, time and clinician | Regulation 4 asks for both, recorded as close to the time as possible |
| Medical history, medicines and GP | Suitability for treatment, and the GP details HIS's records list asks for |
| What the patient wants, and what is realistic | Shows expectations were discussed before consent |
| Risks, side effects and alternatives | The substance of informed consent |
| Price | Patients should know the cost before they agree |
| Time to consider | The interval between consultation and treatment, or the patient's own choice to proceed the same day |
| Signed consent | Patient and practitioner, dated, on the day of treatment |
| Product, dose, batch and expiry | Traceability if there is a complication |
| Injection site record | What was done, and where |
| Unlicensed or off-label use | Discussed and consented to separately |
| Aftercare and how to get help | What the patient was told to watch for |
HIS's guidance does not set a fixed cooling-off period. Patients in Scotland expect time to think before a non-urgent cosmetic treatment, and a record that shows the consultation and the treatment on different days, or the patient's documented choice to go ahead the same day, answers the question before an inspector asks it.
- Send information at booking. The medical questionnaire, the consent form, the risks and the aftercare, before the patient arrives.
- Consult face to face. The prescriber assesses suitability in person, and the outcome is written into the patient care record.
- Discuss, then record the discussion. Risks, alternatives, expected results, price and any unlicensed use, in the clinician's own words in the note.
- Record the interval. The date of consultation and the date of treatment, and if they are the same, that the patient chose to proceed.
- Sign on the day. Patient and practitioner sign and date the consent form on the day of treatment, after the discussion.
- Record what was given. Product, dose, batch number, expiry date and an injection site record.
- Record the aftercare. What the patient was told, and how to reach the clinic if something goes wrong.
- Audit monthly. Pick five records and check every field. Fix how records are made, then check again.
- Patient reference ______ Date and time of consultation ______
- Prescriber ______ Registration body and number ______
- Medical history, medicines, GP ______
- What the patient wants ______ What was advised ______
- Risks, side effects and alternatives discussed ______
- Price quoted ______ Unlicensed or off-label use explained ______
- Date of treatment ______ Same day, patient's choice recorded ______
- Consent signed by patient ______ and practitioner ______ on ______
- Product ______ Dose ______ Batch ______ Expiry ______
- Injection sites recorded ______ Aftercare given ______
When something goes wrong
A complication of dermal filler must be notified to HIS within 24 hours. A serious injury or serious complication to a service user must be notified within 2 working days.5 The consent record and the treatment record are where any review starts.
The Non-surgical Procedures Act 2026
The Non-surgical Procedures and Functions of Medical Reviewers (Scotland) Act 2026 received Royal Assent on 12 May 2026. It prohibits the non-surgical procedures it covers for anyone under 18, and anywhere outside specified premises.6 Permitted premises include a registered independent clinic whose services are provided or managed by a registered medical practitioner, a dentist, or a nurse, midwife or pharmacist independent prescriber, along with registered independent hospitals and registered pharmacies.7
As of 15 October 2026 the premises offence, section 3, is not in force, and the Act says it cannot come into force before 6 September 2027.8 Until then, HIS registration and its consent and record keeping requirements remain the rules an aesthetic clinic is inspected against. The guide to HIS registration for an independent clinic covers registering, and the Healthcare Improvement Scotland hub covers inspection and grades. To see consent recorded at booking and in the signed note on your own clinic's diary, request a demo.
Questions
Does HIS require a cooling-off period?
HIS's published guidance does not set a fixed period. Recording when the consultation and the treatment happened, and the patient's choice if they were on the same day, shows the patient had the chance to consider.
Can consent records be electronic?
HIS asks for a record of consent to treatment, not a paper form. The aesthetics clinic in the September 2026 report kept its records on a password protected electronic system, signed and timed by the practitioner.
Do I need separate consent for unlicensed use?
Inspectors look for it. In the September 2026 report, the unlicensed use of a product was discussed with each patient, and their informed consent was recorded in the patient care record.
Does a nurse led aesthetic clinic register with HIS?
Yes, if it meets the definition of an independent clinic. HIS gives a nurse led cosmetic clinic as an example of a service that must register.
Sources
- 1Healthcare Improvement Scotland, 2019Guidance on records to be kept by registered independent healthcare servicesRead source
- 2legislation.gov.uk, 2011The Healthcare Improvement Scotland (Requirements as to Independent Health Care Services) Regulations 2011, regulation 4Read source
- 3Healthcare Improvement Scotland, 2026Independent healthcare registration guidance for applicants, May 2026Read source
- 4Healthcare Improvement Scotland, 2026Announced inspection report, an aesthetics clinic in Fife, September 2026Read source
- 5Healthcare Improvement Scotland, 2024Independent healthcare regulation, notifications guidance, June 2024Read source
- 6legislation.gov.uk, 2026Non-surgical Procedures and Functions of Medical Reviewers (Scotland) Act 2026, introductory textRead source
- 7legislation.gov.uk, 2026Non-surgical Procedures and Functions of Medical Reviewers (Scotland) Act 2026, section 4Read source
- 8legislation.gov.uk, 2026Non-surgical Procedures and Functions of Medical Reviewers (Scotland) Act 2026, section 24Read source
Written by the wai team from Healthcare Improvement Scotland guidance, checked on 15 October 2026. This is guidance, not legal advice. HIS does not endorse wai or any software.