Dermal Filler Consent PDF Details

Dermal fillers are a popular way to improve the appearance of wrinkles and other signs of aging. However, as with any medical procedure, it is important to understand the risks involved before consenting to treatment. The dermal filler consent form provided by your doctor should outline these risks in detail. If you have any questions or concerns, be sure to discuss them with your doctor before signing the form. By understanding the risks and benefits of dermal fillers, you can make an informed decision about whether this treatment is right for you.

The Dermal Filler Consent Form is essential for protecting both the client and the practitioner by ensuring that the client is well-informed about the procedure and its potential outcomes. Clients should read and understand the consent form thoroughly and ask any questions they may have before signing it.

Form Name Dermal Filler Consent Form
Form Length 3 pages
Fillable? Yes
Fillable fields 21
Avg. time to fill out 4 min 57 sec
Other names dermal filler consent pdf, lip filler consent form, dermal fillers consent form

Form Preview Example

Dermal Filler Consent Form

Name: __________________________________________________________________

Telephone: ______________________________________________________________

Email Address: ___________________________________________________________

Address: ________________________________________________________________

Medications: _____________________________________________________________

Allergies: Women: Are you Pregnant or Lactating? ______________________________

Circle any of the following history you have or have had in the past:


History of Anaphylaxis

Multiple Severe Allergies

Facial Acne

Active Inflammatory process

Infection (at proposed injection site)


Immunosuppressive Therapy

Autoimmune Disease


Facial Rashes

Any Other Medical Disease: ______________________


Previous Hospitalizations/Operations:

I understand the information on this form is essential to determine my medical and cosmetic needs and the provision of treatment. I understand that if any changes occur in my medical history/health I will report it to the office as soon as possible. I have read and understand the above medical questionnaire. I acknowledge that all answers have been recorded truthfully and will not hold any staff member responsible for any errors or omissions that I have made in the completion of the form.

Patient Signature: _____________________________________ Date: ______________


Dermal Filler is a gel of hyaluronic acid generated by streptococcus species of bacteria, chemically cross linked with BDDE, stabilized and suspended in physiologic buffer at PH=7 and concentration of 20 mg/ml. Areas most frequently treated are: nasolabial folds, oral commissures, lips, and Glabellar. Client may experience a slight burning sensation during injections. The procedure takes about 20-30 minutes. Results last approximately six months.


It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include but are not limited to:

1)Post treatment discomfort, swelling, redness, and bruising,

2)Post treatment bacterial, viral, and/or fungal infection requiring further treatment,

3)Allergic reaction


I authorize the taking of clinical photographs ant their use for scientific purposes both in publications and presentation. I understand my identity will be protected.


I am not aware that I am pregnant, have any significant Medical diseases, or have any severe allergies.


I understand that this procedure is cosmetic and that payment is my responsibility.

I hereby voluntarily consent to treatment with Dermal Filler injection for the condition known as: Facial Static Wrinkles. The procedure has been explained to me. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure.

Patient Signature: ____________________________________ Date: _______________

Witness Signature: ___________________________________ Date: _______________

Dental Infiltrate Consent

I, _______________________________ understand that a Dental Infiltrate will be performed to provide

temporary relief of discomfort associated with the administration of dermal filler. I understand that Dental Infiltrates are not 100% effective, but should reduce pain in most cases.

The risks of a Dental Infiltrate include bleeding, infection, and adverse reaction to the anesthetic.

_________ (Initial) I do not have any hypersensitivity to any local anesthetic agents, nor do I have a history of

malignant hyperthermia.

I have read and understand this consent and all of my questions have been addressed and answered to my satisfaction. I have no contraindicating factors, and thereby grant permission for a Dental Infiltrate. I certify that if any changes occur in my medical history/health or regime, that I will notify this office as soon as possible.


Client (Print Name)




Witness (Print Name)



How to Edit Dermal Filler Consent Form Online for Free

It is simple to create documents with the help of our PDF editor. Improving the filler consent for juvederm file is straightforward for those who keep to these actions:

Step 1: Click the orange button "Get Form Here" on the following webpage.

Step 2: Once you access the filler consent for juvederm editing page, there'll be all the actions you can undertake with regards to your document at the upper menu.

These particular areas are included in the PDF document you'll be filling in.

example of spaces in dermal filler consent form pdf

Within the part Circle any of the following note the information the system demands you to do.

dermal filler consent form pdf Circle any of the following fields to insert

The software will request for additional info to automatically fill in the box PREGNANCY.

part 3 to entering details in dermal filler consent form pdf

The The risks of a Dental Infiltrate, and I have read and understand this section is where either side can insert their rights and responsibilities.

step 4 to finishing dermal filler consent form pdf

End by reviewing the following fields and filling out the relevant details: .

stage 5 to completing dermal filler consent form pdf

Step 3: Click the "Done" button. Now you can export the PDF document to your device. Additionally, you can easily send it through email.

Step 4: Attempt to get as many copies of the document as you can to keep away from future issues.

Watch Dermal Filler Consent Form Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .