Dermal Filler Consultation/Consent Form | Aesthetics Forms Portal

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Dermal Filler Consultation and Consent Form

Covid-19 Screening

To ensure the safety of all parties and to stop the further spread of the Covid-19 virus, please complete the below questions as honestly and accurately as possible prior to your appointment date.

1. Have you, or anyone in your household, had Covid-19 in the last 14 days? *

Please give details: *

2. Are you, or anyone in your household, awaiting test results for Covid-19? *

Please give details: *

3. Have you, or anyone in your household, had any of the following symptoms in the last 14 days: Continuous cough, Fever, High temperature, Loss of sense of taste, Loss of sense of smell? *

Please give details: *

4. Have you, or anyone in your household, been in contact with anyone with confirmed Covid-19 in the last 14 days? *

Please give details: *

5. Have you, or anyone in your household, travelled outside the US in the past 14 days? *

Please give details: *

6. Have you received a Covid-19 vaccine? *

Which vaccine did you receive? *

Have you received one or two doses? *

When did you receive the first dose? *

When did you receive the second dose? *

Appointment Guidance

If you have answered yes to any of the above questions we will be in contact as you may need to reschedule your appointment with us.
Please only attend at your appointment time.
Please ensure you are on time - if you are late this may result in your appointment being cancelled.
Please attend your appointment unaccompanied.
Please limit the personal possessions you bring with you.
Please wear a face mask/covering to your appointment.
Upon arrival please wait until you are called forward to reception.
Upon arrival please use the hand sanitiser provided.
Please maintain social distancing where possible.
If you experience Covid-19 symptoms after your appointment please contact us immediately.

Please tick each statement to show your understanding and agreement. *

I’m willing to get my body temperature checked before beginning my salon/clinic services. If my temperature is above 37 degrees celsius I agree to not visit the salon/clinic for the next 14 days I agree not to visit the salon/clinic for any of the services provided if I have the symptoms of Covid-19. I acknowledge that the information I have given in this consent form is accurate and complete. By signing below I confirm that I understand and agree to all terms and statements in this form.

Client Signature: *

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Client Details

Full Name: *

Date of Birth: *

Contact Number: *

Email: *

Are you currently taking any medications (oral or topical)? *

Please list: *

Do you have any allergies? *

Please list: *

Health Information

1. Have you had any treatment with dermal fillers (e.g. Absorbable dermal fillers, Semi permanent dermal fillers, or Botulinum toxin)? *

Which treatment(s) have you received, which areas were treated, and when did you receive the treatment(s)? *

2. Have you ever suffered from an auto-immune disease or any condition affecting the immune system? *

Please specify: *

3. Do you have any cutaneous (skin) infection or inflammatory problems (e.g. herpes/cold-sores, acne etc.)? *

Please specify: *

4. Are you taking any steroids, aspirin or anticoagulant (i.e. warfarin, apixaban etc.)? *

Please specify: *

5. Do you suffer from acute rheumatic fever or recurrent sore throat? *

Please specify: *

6. Have you ever experienced a reaction to hyaluronic acid, amide type local anaesthetics or lidocaine? *

Please specify: *

7. Do you suffer from epilepsy? *

Please specify: *

8. Do you tend to develop hypertrophic scarring? *

Please specify: *

9. Do you suffer from cardiac conduction disorders (heart rhythm problems etc.)? *

Please specify: *

10. Do you have any other medical conditions? *

Please specify: *

Post-treatment Guidelines

- You may initially be swollen, red and bruised. This should subside within the next 10 days.
- It is advisable that you do not touch the area for six hours.
- Do not apply make-up or any other cosmetics for twelve hours, unless the products are mineral based.
- Avoid exposure to direct sunlight, UV, or extreme heat (i.e. sauna, steam rooms, sunbeds etc.) for two weeks as this may increase discomfort and swelling.
- Avoid extreme cold (i.e. ice packs) for two weeks. If necessary, you can apply a cool compress to the area, to reduce any discomfort or swelling.
- Arnica tablets/gels can be used to help reduce bruising or the application of vitamin K Oxide cream.
- If you have had a local nerve infiltration injection, please do not consume any hot or cold drinks until your sensation has returned to normal.
- Be very careful not to bite or chew your lip when eating.
- If you experience any lumpiness in the implantation area, it can be gently massaged to help smooth this out.
- You should avoid any facial massages, or skin resurfacing until the area has fully healed.
- Avoid extreme facial expressions for twelve hours.
- Avoid all alcohol consumption for twelve hours.

Consent

Consent Statements

Please read the following information carefully and tick the boxes to show your understanding and agreement:
Due to the use of a needle there is likely to be some bleeding at the injection site.	.
Reactions giving rise to, for example redness and swelling may occur after the injection and this may be associated with stinging, itching or discomfort upon pressure at the injection site. This reaction may last for several days.	.
Indurations or nodules may develop at the injection site.	.
If any symptoms persist for more than one week, or if any other side effects develop, please report them to the practitioner as soon as possible so that they can advise the best course of treatment.	.
The aesthetic effects of the filler can last up to 12 months, but will vary depending on the condition of the skin area treated, amount of product injected, injection technique and lifestyle factors, such as sun exposure and smoking.	.
I understand that the treatment may involve the risk of complication or injury and I freely assume those risks.	.
I have read the contents of this consent form carefully and I fully understand it. I have been given the opportunity for discussion pertaining to the treatment and all my questions have been answered to my satisfaction. I hereby release the practitioner against any and all liability associated with this procedure. I have been adequately informed of the risks and benefits of this treatment and wish to proceed with the treatment.	.

Signature: *

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