DERMAL FILLER TREATMENT CONSENT FORM
Patient Information
Full Name:
Date of Birth:
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Phone Number:
Format: 00000000000.
Email:
example@example.com
Treatment Details
Treatment Area(s):
Date of Treatment:
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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Medical History
Please tick if you have any of the following:
Allergies (please specify):
Other
Pregnancy or breastfeeding
Autoimmune disease
Skin infections or inflammation in treatment area
History of cold sores/herpes simplex
Previous dermal fillers or cosmetic treatments
Bleeding disorders or use of blood-thinning medication
Any other medical conditions:
Other
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Treatment Information
Dermal fillers are injectable treatments used to restore volume,
enhance facial contours, and reduce the appearance of lines and
wrinkles. Results are temporary and vary between individuals.
Photography Consent (Optional)
I consent to photographs being taken for medical records
I consent to use of images for marketing/education
Patient Signature:
Date:
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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