Dermal Filler Consultation Form

Collect a client's medical background and general details ahead of a dermal filler session so you can plan the treatment safely and confidently.

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Full Name

Nombre

Apellido

Date of Birth

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Are you currently receiving any medical or dental treatment?

Yes No

Please give details

In the last month, have you had any dermal treatments such as tattoos, dermal fillers, piercings, or botulinum toxin?

Yes No

Please give details

Do you have any allergies to your knowledge?

Yes No

Please give details

Do you have any relevant past medical history?

Yes No

Please give details

Have you recently received your COVID-19 vaccination?

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 give details

Is there anything you'd like to add?

Confirmation

I confirm that the information provided is accurate to the best of my knowledge.

Signature

Sign here

Date

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