Dermal Filler Consent Form v1

Name *

First Name

Last Name

Date of Birth *

MM/DD/YYYY

MM

DD

YYYY

Are you pregnant or breast feeding? *

Yes

No

Have you a history of sever allergy/anaphylaxis? *

Yes

No

Have you previously received any aesthetic treatments? *

e.g. laser peels, dermoabrasion etc

Yes

No

Have you had any treatment with dermal fillers, absorbable dermal fillers, semi-permanent dermal fillers or botulinum toxin? *

Yes

No

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

Yes

No

Do you have any cutaneous (skin) infection or inflammatory problems? *

e.g. herpes (cold-sores) acne etc.

Yes

No

Are you taking any steroids, aspirin or anticoagulant? *

i.e. warfarin, apixaban, rivaroxaban etc.

Yes

No

Do you duffer from any allergies, specifically allergies to hyaluronic acid, amide type local anaesthetics or lidocane? *

Yes

No

Do you suffer from untreated epilepsy? *

Yes

No

Do you develop hypertrophic scarring? *

Yes

No

Do you suffer from cardiac conduction disorders? *

e.g. heart rhythm problems etc.

Yes

No