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Dermal Filler Consent Form

A dermal filler consent template — capture informed consent before filler, covering the areas, risks, aftercare and no guarantee.

Description

Dermal filler is a medical procedure, and informed consent is both a requirement and a protection. This dermal filler consent form records that a client understood the treatment, the risks and the aftercare before it went ahead.

It captures the client’s name and date of treatment, the areas being treated, and confirmation that their medical history has been reviewed. It sets out the risks, the aftercare, and that no specific result is guaranteed, and takes their consent and signature.

Use it before every filler treatment, with the medical history reviewed the same day. A signed, dated consent shows the client was fully informed. Customize the risks and aftercare to fit your protocols, add your branding, and embed it on your site or share a link in minutes.

Form fields

Everything the Dermal Filler Consent Form above collects — 11 fields across 2 pages, so you can see exactly what it captures before you make it your own.

Dermal Filler Consent

  • Full name

    Name Icon
    Name
  • Date of treatment

    Date Icon
    Date
  • Areas being treated

    Multi-Select Icon
    Multi-Select
  • Has your medical history been reviewed today?

    Yes/No Icon
    Yes/No

Understanding & consent

  • Risks

    Consent Icon
    Consent
  • Aftercare

    Consent Icon
    Consent
  • No guarantee

    Consent Icon
    Consent
  • Consent

    Consent Icon
    Consent
  • Signature

    Signature Icon
    Signature
  • Email address

    Email Icon
    Email
  • Contact number

    Telephone Icon
    Telephone
Use Template Arrow Right Icon

Template FAQs

Common questions about the Dermal Filler Consent Form — what it captures, when to use it, and how to make it your own.

What is a dermal filler consent form?

A dermal filler consent form records that a client agreed to filler treatment after being informed of the risks, aftercare and limitations. It’s a professional and legal requirement for a medical procedure, and it protects the client and the practitioner.

What should a dermal filler consent form include?

This form captures the client’s name and date of treatment, the areas being treated, confirmation their medical history has been reviewed, the risks, the aftercare, a no-guarantee statement, and the client’s consent and signature.

When should a client sign a filler consent form?

Before treatment begins, on the day, with their medical history reviewed the same day. Consent must be informed and given beforehand — signing before treatment means the client has genuinely understood the risks and aftercare and agreed to proceed.

Who needs to sign a dermal filler consent form?

Every client, before every filler treatment. The form captures their signature and confirms the risks and aftercare were explained, so there’s a clear record for each treatment that the client was informed and consented.

Why include aftercare in a filler consent form?

Because how a client cares for the area affects healing and results, and setting it out is part of informed consent. Capturing that the aftercare was explained protects the client and the practitioner, and gives the client a clear reference for what to do next.

Is this dermal filler consent template free?

Yes, completely free. Adjust the risks and aftercare to match your own protocols, and restyle it to your brand, then embed it on your site or share a link — no coding needed. A free Fun Forms account lets you collect signed consent. Always use your own clinically approved wording.