Dermal Filler Consultation/Consent Form | Aesthetics Forms Portal - Paperless Mission Control

Dermal Filler Consultation and Consent Form

Client Details

Full Name: *

Contact Number: *

Date of Birth: *

Email: *

Medical History

Please list: *

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

Please list: *

Are you currently receiving any medical treatment? *

Do you have any allergies? *

Please list: *

Are you (or is there a possibility you may be) pregnant, or are you breastfeeding? *

Have you been unwell recently? *

Which of the following were you unwell with? *

Please provide more details: *

Do you have any surgery planned in the next 6 months? *

Please provide more details: *

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

Please provide more details: *

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

Please provide more details: *

Do you have any history of anaphylactic shock or severe allergic reactions? *

Please provide more details: *

Do you tend to develop hypertrophic scarring? *

Please provide more detail: *

Have you previously had any Dermal Filler or Botulinum Toxin? *

Which treatment did you receive, what areas were treated and when? *

Have you previously had any sensitivity to hyaluronic acid based products, any dermal filler, lidocaine or local anaesthetics? *

Please specify: *

Are you undergoing any dental work or have any dental work/hygienist planned? *

Please specify: *

Do you have any metal plates in your face? *

Please provide more detail: *

Have you taken any Aspirin, Ibuprofen, Fish Oil, Vitamin E in the last five days? *

Please specify: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Dermal Filler Treatment

Dermal fillers are injected under the skin with a very fine needle/canaula. This produces natural appearing volume, shape and contour of the lips, cheeks, chin and jaw and folds which are lifted up and smoothed out. The results can often be seen immediately.

If have any questions regarding the procedure, ask trainer prior to signing the consent form.

What would you like the treatment to improve or change about your appearance? *

I consent to the use of natural Hyaluronic Acid fillers that are FDA approved such as Restylane, Juvederm & Revanesse. If these are unavailable at time of appointment, do you consent to the use of a comparable filler with equivalent efficacy and durability? *

YES

Possible Risks and Complications

Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free.

The possible risks of Dermal Filler include, but are not limited to:

Post treatment discomfort, swelling, redness, bruising, and discoloration
Post treatment infection associated with any transcutaneous injection
Allergic reaction
Reactivation of herpes (cold sores)
Lumpiness, visible yellow or white patches
Granuloma formation
Localized necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs
Vision complications

Aftercare Advice

Please read carefully.

The goal of aftercare is to encourage optimal treatment results. It can also minimize the risk of bruising and spreading to other areas. Follow the aftercare advice provided for optimal results.

Don’t touch your skin. Take a break from makeup for 24 hours and don't touch your face. Applying makeup will rub the skin, potentially dispersing the toxin.
Wait 24 hours to exercise. If exercise is part of your daily routine, wait at least 24 hours to work out. Physical activity increases blood flow. This could potentially spread the toxin to unintended areas and reduce its effectiveness at the injection site. It also increases the risk of bruising. Exercise also contracts your muscles, which may decrease the toxin’s effectiveness.
Sit up. Sit up for the first 4 hours after getting Dermal Filler. Bending or lying down might spread the toxin and promote bruising.
Medication. Some medications might increase your risk of bruising. Be sure to ask your practitioner when it’s safe to start taking them again. Avoid aspirin and ibuprofen for a few days following treatment. Do not restart Retinol or Retin-A for 2 days.
Don’t drink alcohol. Alcohol increases the risk of bruising. Wait at least 48 hours after your treatment before consuming alcohol.
Don't massage, rub or apply pressure to the treated area.
Don’t sleep on the treated areas. Try your best to avoid sleeping on the injected areas. This will minimize the physical pressure and let the Dermal Filler settle into your muscles. Also, avoid sleeping within 4 hours after your procedure.
Stay out of the sun. Avoid sun exposure for at least 48 hours. The heat can promote flushing and increase your blood pressure, which may encourage bruising.
Avoid heat exposure. It’s also best to avoid other forms of heat exposure, such as: Tanning bed, Hot tubs, Hot showers or baths and Saunas.
Apply ice. You can apply a pack of ice for relief. The bruising should go away in about 2 weeks.
Apply topical cream. You can apply Arnica cream to any areas with redness, bruising or swelling.
Avoid waxing and use of chemical depilatories for 1 week following treatment.
Wait before having more Aesthetic treatments. Avoid facials, chemical peels, micro-dermabrasion for 2 weeks following treatment. Radio frequency miconeedling must be avoided for 4 weeks.

Please tick the box to confirm: *

I have read and understood the aftercare advice given to me on this form.

Consent

I accept that any treatment I am going to receive is at my own risk.

I certify that I have read, fully understood, and completed this form to the best of my knowledge.

I understand that failure to disclose information requested above may result in adverse side effect(s), unknown because of this to which I accept full liability/responsibility.

The treatment(s) and possible side effect(s) have been fully explained to me.

I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request.

I accept that if I am not satisfied with the treatment I will inform the practitioner immediately.

I fully understand the above and consent to receive Dermal Filler.

Signature: *

Tap or click on the signature above to sign

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