Dermal Filler Client Intake Form

Collect a client's medical history and expectations ahead of a dermal filler session, including allergies and prior procedures.

Use this template

Name

First Name

Last Name

Day of Birth

Address

Street Address

City

State / Province

ZIP / Postal Code

Phone Number

Email

Allergies

Medical Conditions

Diabetes Heart Disease Blood Clotting Disorder Autoimmune Disease None

Other medical problems not listed above should be included and/or explained:

Have you ever had a plastic surgery?

Yes No

If the answer is yes, please explain it more detailed way.

Have you had Dermal Filler before?

Yes No

If the answer is yes, please explain it more detailed way.

Date

Patient Signature

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