Aesthetic Injection Consent Form
Use this form to record client details, planned injection information, relevant screening, and consent for an aesthetic injection appointment.
Client Details
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Injection Details and Medical Screening
Planned Injection Areas
*
Forehead
Frown lines
Crow’s feet
Lips
Cheeks
Jawline
Chin
Neck
Other
Product / Treatment Type
*
Please Select
Botulinum toxin
Dermal filler
Skin booster
Other
Appointment Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Current Health / Medication Screening
*
Consent and Acknowledgment
Consent Acknowledgment
*
I understand the procedure is elective and may have temporary effects, including bruising, swelling, asymmetry, infection, or dissatisfaction. I agree to follow the aftercare instructions provided.
Client Signature
*
Submit
Submit
Should be Empty: