Patient Information

Full Name: *

Date of Birth: *

Age: *

Phone Number: *

Email Address: *

Emergency Contact Name: *

Emergency Contact Phone: *

Medical History

Women only:

Are you pregnant, trying to conceive, or breastfeeding?

Yes

No

Medications & Skin Sensitivity

Are you currently taking any medications? (e.g., blood thinners, aspirin, NSAIDs, steroids, Accutane)

Yes

No

If yes, list:

Have you had previous filler treatments?

Yes

No

If yes, when?

Do you have any allergies to medications, numbing agents, or skincare products?

Yes

No

If yes, list:

Have you had recent cosmetic treatments (e.g., Botox, laser, microneedling, chemical peels)?

Yes

No

If yes, list:

Treatment Information & Risks

Dermal fillers are injectable treatments used to restore volume, enhance facial contours, and reduce wrinkles. Common areas include lips, cheeks, jawline, and under-eye hollows.

Possible side effects include but are not limited to: *

Temporary redness, swelling, or bruising at the injection site.

Mild discomfort or tenderness.

Risk of infection if aftercare instructions are not followed.

Uneven results or lumps, which may require adjustment.

Rare but serious complications, including vascular occlusion, allergic reactions, or tissue damage.

Contraindications:

Dermal fillers are NOT recommended if you:

• Have an active skin infection, cold sores, or open wounds.

• Have severe allergies or a history of anaphylaxis.

• Have a bleeding disorder or take blood thinners (unless cleared by a doctor).

• Are pregnant or breastfeeding.

• Have had recent dental work (within two weeks).

Consent & Acknowledgment

I acknowledge that: *

I have disclosed all medical conditions, medications, and relevant history to the best of my knowledge.

I understand the potential risks, side effects, and healing process of dermal fillers.

I have been informed that results vary from person to person and that touch-ups may be required.

I understand that swelling and bruising are common and that final results may take up to two weeks.

I will follow all pre- and post-treatment care instructions provided to me.

I consent to the dermal filler treatment and understand the risks involved.

Client Name (Print): *

Client Signature: *

Clear

Date: *

Practitioner Name (Print): *

Practitioner Signature: *

Clear

Date: *

I agree to terms & conditions provided by the company.

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