Dermal Filler Consultation Form
Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you currently taking any medical or dental treatment?
Yes
No
Please give details
In the last one month, have you had any dermal treatments such as tattoos, dermal fillers, piercings or botulinum toxin?
Yes
No
Please give details
Do you have any allergies in your knowledge?
Yes
No
Please give details
Do you have any relevant past medical history
Yes
No
Please give details
Have you recently received your COVID-19 vaccination?
Yes
No
Please select if you you suffer from any of the conditions listed below
Blood Bourne Virus
Epilepsy
Respiratory Conditions
Myasthenia gravis or Eaton Lamberts Syndrome
Immunodeficiency
Herpes Simplex Virus (Coldsores)
Hypertrophic Scarring
Rheumatic Fever
Acne or Inflammatory Skin Conditions
Blood Disorders
Anaphylaxis/severe allergy
Porphyria
Cardiac Conditions
Recurrent Sore Throats
None of the above
Other
Please give details
Do you want to add something?
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I confirm that all information indicated in this form is true and accurate.
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Date
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Month
 -
Day
Year
Date
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