Dermal Filler Treatment Medical Consent Form

Full Name
First NameLast Name
Date of Birth
YearMonthDay
Date
Contact number
Area CodePhone Number
E-mail
example@example.com
Are you pregnant or breastfeeding?
Do you have any history of severe allergy/anaphylaxis?
Are you currently receiving any medical treatment?
Have you recently undergone any medical or dental treatment/surgery?
If yes to any of the previous questions, please give details in the box 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, 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 Form for Dermal Filler Treatment
Please read carefully and sign after reading. All risks and side effects will be discussed at your appointment with your practitioner. Any questions you have will also be answered.
I have been given sufficient information to enable me to understand the use of the product for the approved indications.
I have also received information regarding contra-indications to the administration of products and potential side effects.
I have been informed that the treatment is carried out by injection, for the improvement of lines/wrinkles and folds of the skin, for lip augmentation and rehydration of the skin.
Some redness, swelling and bruising may occur after treatment associated with possible discomfort, itching and discolouration at the injection site. Resolution is typically spontaneous within a few days.
As with all injectable treatments, there is a minimal risk of infection, vascular occlusion and hypersensitive reaction.
Persistence of inflammatory reaction for more than one week, or the development of any other side effects must be reported to the practitioner as soon as possible.
The effect and length of the results may vary depending on the condition of the skin, mechanical action in the treatment area and the amount of product injected.
Lifestyle factors also affect the duration of the product.
Regular top-up treatments help to optimise the duration of the product.
Post Treatment: Following treatment, avoid strenuous exercise and alcohol
Avoid manipulation of the treated area and make-up, as instructed by practitioner.
I have been informed about the treatment effects of these ranges of products and I consent to the treatment detailed on this form.
The potential benefits and any risks have been fully explained.
Please sign the consent form.
Signature
Clear
If you answered yes to any of the questions within the medical questionnaire, your practitioner may ask for further details. Treatment may be refused if it is not considered in your own interest to proceed.
Click submit to complete your form. Thank you, VLS Aesthetics.
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