Dermal Fillers Consultation and Consent Form

1. Client Demographic Information *

First Name *

Last Name *

Address Line 1 *

Address Line 2

Email *

Phone Number *

Select Gender (Optional)

Birthday

Referred By

Medical History & Skin Analysis

2. Are you currently under the care of a doctor or dermatologist?

YesNo

3. If "Yes" please specify4. Do you have any of the following conditions? Please answer truthfully, this ensures your treatment is safe and effective5. If "Yes" to any of these including current medication" or "Other Medical Condition", please specify

Treatment & History

6. Treatment Selection - Please select the treatment you're booked for:7. If "Other" please specify8. When is the appointment scheduled? *

9. Please tick all that apply:

Anti-wrinkle injections in the pastDermal fillers in the pastFiller dissolving in the pastSkin boosters/mesotherapy in the pastLaser or chemical peel treatment in the past 6 weeksDental treatment in the past 2 weeksNone of the above

10. If yes, specify area and date

Contraindication Check

Please read carefully. Some conditions listed below are absolute contraindications, meaning treatment cannot be carried out under any circumstances. Others are relative contraindications, meaning treatment may still be possible but requires adjustment, additional precautions, or postponing the procedure.

Declaring these honestly is essential to protect your safety, prevent complications, and ensure the practitioner can choose the safest and most effective treatment approach.

11. Please tick any that apply:

Pregnancy or breastfeedingActive infection near treatment areaRecent dental infection or invasive dental treatmentHistory of keloid scarring or poor wound healingKnown hypersensitivity to filler ingredientsBleeding or clotting disorderNone of the above

12. Are you currently on any of the following?

Retinol / Vitamin AAHA/BHA exfoliantsPrescription acne treatment (for example isotretinoin)Blood-thinning medication or supplementsSteroid or immunosuppressive medicationOther active products/medicationsNone of the above

Client's Consent (Mandatory)

Photographs are taken before and after treatment for medical documentation and client records.

13. Client Consent (Mandatory) Please confirm each statement: *

I confirm that I have read, understood, and agree to follow the pre- and post-treatment information guide provided with this consultation and consent form.I confirm that the information I have provided is accurate, and I have disclosed all relevant medical history and allergies.I understand the general risks associated with aesthetic treatments, including bruising, swelling, asymmetry, infection, or temporary discomfort.I understand that results vary between individuals and that I may require further treatment for optimal or maintained results.I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction.I understand that all aesthetic treatments provide temporary results and will naturally wear off over time.I consent to photographs being taken for my medical record, with optional separate consent for marketing below.I consent to the processing of my personal data in accordance with the clinic's privacy policy and understand I can withdraw consent at any time.

14. Photo & Marketing Consent. *

I consent to my photos being used anonymously for training or educational purposes.I consent to my photos being used on social media/marketing.I do not consent to any use of my photos beyond my medical record.I consent to receive emails with offers and updates.

15. Please sign and date to confirm that you have read, understood, and agree to the statements above. *

I agree to use electronic records and signatures.15. Customer's Signature

Draw signature

Customer SignatureTimestamp captured on sign

Signature Date16. Client's Name *I agree to use electronic records and signatures.17. Employee's Signature

Draw signature

Employee SignatureTimestamp captured on sign

Employee Signature Date18. Employee's Name

Note: Customers will not see the employee signature field when filling form online.

Practitioner Notes (For Internal Use Only)

19. For "Other", please specify area:Assessment:Batch Number & Expiry Date:Treatment Given / Units Used:Post-Treatment Comments:

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Dermal Fillers Consultation & Consent Form

Dermal Fillers Consultation & Consent Form