Dermal Filler Treatment Medical Consent Form

Lets patients review their health history and grant medical consent online before starting a dermal filler treatment.

Use this template

Full Name

First Name

Last Name

Date of Birth

Contact Number

E-mail

Are you pregnant or breastfeeding?

Do you have any history of severe allergy or anaphylaxis?

Are you currently receiving any medical treatment?

Have you recently undergone any medical or dental treatment or surgery?

If you answered yes to any of the previous questions, please give details below:

Do you suffer from keloid or hypertrophic scarring?

Do you have a phobia of needles or suffer from fainting attacks?

Have you had any dermal filler treatment?

If yes, which treatment did you receive, in what areas, and when?

Do you have any skin infections or inflammatory problems (e.g. herpes, acne, etc.)?

Do you suffer from any allergies?

If yes, please give details:

Consent Declaration

Signature

Sign here

Additional Notes

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