Dermal Filler Consent Form Template
Obtain informed consent before any dermal filler treatment. Capture the client's medical history, treatment details, risk acknowledgment, and signature before the first injection.
Dermal filler procedures carry real risks — and clients need to understand them before treatment begins. A thorough consent form explains the procedure, the specific product being used, potential side effects ranging from bruising to vascular occlusion, contraindications, aftercare requirements, and the client's right to ask questions — creating a documented record that protects both the practitioner and the client.
This template covers client personal and contact details, current medications and supplements (especially blood thinners), known allergies, previous filler treatments and any reactions, contraindications checklist (pregnancy, autoimmune conditions, active infection), the areas to be treated and product to be used, a list of possible side effects and risks with severity ratings, aftercare instructions acknowledgment, and a signature confirming informed consent.
Aesthetic clinics, medical spas, dermatology practices, and plastic surgery centers use filler consent forms before every treatment session. Send the form digitally ahead of the appointment so clients read it carefully rather than signing in a rush at the front desk. Store signed consents in the client's treatment record and update before each subsequent session.
Yes — consent should be obtained before every treatment, not just the first. Products, areas treated, and the client's health status can change between appointments.
Yes — send the form link by email or SMS ahead of the appointment. Clients complete it at their own pace and can ask questions at arrival.
Blood thinners, NSAIDs, fish oil, vitamin E, and certain herbal supplements increase bruising risk. The consent form should list common examples and ask clients to disclose all current medications.
In most jurisdictions, yes. Confirm requirements with your legal advisor and ensure the form captures a time stamp and clear confirmation of intent.
Follow your jurisdiction's medical records retention requirements — typically a minimum of seven years. Store alongside the client's treatment notes and product batch records.
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