Templates · Free template · Injectable consent

Dermal Filler Consent Form Template

A printable dermal filler consent form covering the common and serious risks, the alternatives, realistic expectations, and the aftercare instructions a client acknowledges before treatment.

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Last reviewed September 2026 · Not legal advice

Part of the Dermal and lip filler treatment guide →

Consent is a conversation the form records

The form is not a substitute for explaining the treatment. It records that you did: what filler is, what it can and cannot do, the common effects such as swelling and bruising, and the rare but serious ones, including vascular occlusion. Clients should be able to say in their own words what they agreed to.

Include the alternatives, including not treating, and the aftercare rules. Record who reviewed the form with the client and when, since consent is judged on the conversation as much as the signature.

Clinic name · address · phone

Dermal Filler Consent Form

Client

Full name

Date of birth

Phone

Health

Pregnant or breastfeeding? Yes No

Allergy to lidocaine or hyaluronic acid? Yes NoIf yes, details

On blood thinners or aspirin? Yes NoIf yes, details

History of cold sores? Yes No

Previous filler in the area? Yes NoIf yes, details

Autoimmune condition or active infection? Yes NoIf yes, details

Risks and acknowledgements

Initial each item to confirm you have read and understood it.

InitialsI understand results vary and may need touch-up treatment, and are not permanent.

InitialsI understand the common effects include swelling, bruising, tenderness, redness, and lumps.

InitialsI understand rare risks include infection, allergic reaction, asymmetry, migration, and blockage of a blood vessel that may cause tissue damage or vision changes.

InitialsI understand alternatives exist, including no treatment.

InitialsI have been told what to do and who to call if I have concerns after treatment.

Consent

Areas to be treated

I have had the chance to ask questions
I received the aftercare instructions
I consent to treatment

Signatures

Client / patient signature

Date

Practitioner name and signature

Date

Template from zdrovia.ca/templates/dermal-filler-consent-form/ · Review with your medical director, regulatory college guidance, and insurer before use.

Send this form before the appointment instead of printing it

Zdrovia's form builder turns this template into a digital form your clients sign on their own phone. The signed copy files into their chart with the exact version they saw, and photo consent stays separate from treatment consent. It's free for solo practitioners, with data stored in Canada.

Start free, no card required See how digital forms work →

See how Zdrovia is set up for med spas.

Frequently asked questions

Does the form need to mention vascular occlusion?

Serious risks should be explained to the patient and recorded. Ask your insurer and medical director how they want it worded.

Can consent be given digitally?

Digital signatures are widely used in clinics. Confirm your regulator's expectations.

This template is a starting point for discussion with your team and advisors, not legal or medical advice. Requirements vary by province and profession. Have your medical director, your regulatory college's guidance, and your malpractice insurer confirm the wording before you use it with patients.