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Dermal Filler Consent Form Template

Streamline your consent process with this essential template

Managing client consents can be a complex task that takes time away from your practice. This dermal filler consent form template is designed to help aestheticians and clinics efficiently gather necessary consent from clients before any procedures. By using this template, you can ensure compliance, enhance client safety, and improve your workflow, all while maintaining a professional approach to patient care. You can easily customize the form, print it out, or send it digitally-explore this ready-to-use template now.

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Full name
Date of birth
Email address
Mobile phone number
Home address
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Emergency contact full name
Relationship to you
Emergency contact phone
Permission to contact this person in an emergency
Yes
No
Are you currently pregnant or breastfeeding?
Yes
No
Do you have any known allergy to lidocaine (local anesthetic)?
Yes
No
Not sure
Do you have any known allergy to hyaluronic acid fillers?
Yes
No
Not sure
Do you have any known allergy to hyaluronidase (used to dissolve fillers)?
Yes
No
Not sure
History of severe allergies or anaphylaxis
Yes
No
List any allergies (medications, foods, materials). If none, enter N/A.
Do you have a condition that affects your immune system?
Yes
No
Not sure
Do you have a history of keloid or hypertrophic scarring?
Yes
No
Not sure
Do you currently have any skin issues in or near the treatment area (e.g., infection, rash, open wound)?
Yes
No
Not sure
Have you ever had cold sores (herpes simplex) near the mouth or nose?
Yes
No
Not sure
Are you taking blood thinners, aspirin, NSAIDs, high-dose fish oil, or herbal supplements that increase bleeding?
Yes
No
Not sure
List current medications and supplements. If none, enter N/A.
Have you had facial surgery or aesthetic treatments (e.g., fillers, threads, lasers) in the last 24 months?
Yes
No
Not sure
Provide details of any previous procedures including product names and dates. If none, enter N/A.
Have you had dental work within the last 2 weeks or planned within the next 2 weeks?
Yes
No
Not sure
Areas you wish to treat
Please Specify:
If you selected Other, specify the area
Previous dermal filler experience
Never
Within the last 6 months
6-12 months ago
More than 12 months ago
Describe your desired outcome
Pain management preference
No anesthetic
Topical numbing cream
Local anesthetic injection
Not sure
I understand common short-term effects may include redness, swelling, tenderness, and bruising.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I understand rare but serious risks include infection, vascular occlusion, tissue loss, and vision changes, and that urgent treatment may be required.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I understand results are temporary, can vary, and no specific outcome is guaranteed. Additional treatments may be needed.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I have received and understand pre- and post-treatment care instructions and know whom to contact for urgent concerns.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I will avoid alcohol, blood thinners (unless prescribed by my clinician), and strenuous exercise for 24 hours before and after treatment unless otherwise advised.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
In the event of a complication, I authorize the practitioner to provide appropriate care, which may include hyaluronidase to dissolve filler.
Yes
No
Not sure
I consent to receive dermal filler treatment as discussed today.
Yes
No
I confirm the information provided is true and complete to the best of my knowledge.
True
False
I consent to clinical photos for my medical record
Yes
No
I consent to the use of my photos for marketing (e.g., website, social media)
Yes
No
Only if I provide additional written permission
Preferred contact method for follow-up
Email
Phone call
Text message
No follow-up contact
Best times to contact you
Morning
Afternoon
Evening
Weekend
Anytime
Type your full legal name as your electronic signature
Date of signature
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Paper art illustration showcasing a consent form template for dermal fillers in a professional setting.

When to use this form

Use this consent before any injectable appointment, including first-time visits, touch-ups, or when changing products or treatment areas. It suits medical spas, aesthetic clinics, nurse injectors, and dental offices that provide cosmetic injections. The form captures health history, contraindications, risk acknowledgments, photo permission, and aftercare agreement so you can treat safely and document informed consent. Send it in advance for e-signatures or complete it on a tablet at check-in to keep sessions on time. If you also gather broader background details, pair it with the Spa client intake form. Studios that offer makeup services can align records with the Makeup consultation form.

Must Ask Dermal Filler Consent Questions

  1. Do you have any allergies, medical conditions, or medications (for example, blood thinners or isotretinoin)?

    This flags contraindications and helps you reduce the risk of bruising, swelling, or infection. It guides product choice, dosing, or the decision to defer treatment.

  2. What injectables or cosmetic procedures have you had in the treatment area, and when?

    Prior filler, threads, or lasers change anatomy and placement options. Date details help you avoid overfilling and unwanted interactions.

  3. Are you pregnant, breastfeeding, or planning vaccines, dental work, or air travel within the next two weeks?

    Timing affects inflammation, infection risk, and your availability for follow-up. This lets you schedule responsibly and set clear expectations.

  4. Do you understand the benefits, risks, alternatives, and potential side effects, and do you give informed consent?

    Documenting informed consent protects you and your clients and meets regulatory standards. Initialing key risks shows that your client read and agreed.

  5. Do you agree to follow aftercare instructions and do you allow clinical photos for records?

    Adhering to aftercare improves results and reduces complaints. Photos create a baseline and, if you offer other services, you can mirror your approach from the Lash lift & tint consent form.

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