Dermal Filler Consent Form

Capture a patient's informed authorization before administering dermal filler injections, covering health history and signature in one streamlined form.

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Full Name

First Name

Last Name

Date of Birth

Phone Number

Are you currently taking any medication?

Yes No

Please specify

As far as you know, do you have any allergies?

Yes No

Please specify

Have you had any previous treatment with dermal fillers, such as absorbable fillers, semi-permanent fillers, or botulinum toxin?

Yes No

Please specify

Are you pregnant or breastfeeding?

Yes No

Please select if you suffer from any of the conditions listed below

Diabetes Autoimmune disorder Cold sores (herpes simplex) Bleeding disorder Keloid scarring None of the above

Please specify

Consent Statement

I agree with the following statements:

I have read and understood the risks and information provided and consent to the dermal filler treatment.

Date

Signature

Sign here

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