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Combined Injectables Consent Form Template

A printable single consent for clients receiving neurotoxin and filler in the same visit, with shared screening and risks listed separately by product.

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Last reviewed September 2026 · Not legal advice

One visit, two sets of risks

Clients who have both treatments in one visit still need to understand each product's risks. Keep them in separate sections so the form is not a blur of small print, and so that either can be updated independently.

Shared screening, such as pregnancy, allergies, and medications, only needs to be asked once. Product-specific details should be recorded on the treatment chart.

Clinic name · address · phone

Combined Injectables Consent Form

Client

Full name

Date of birth

Phone

Shared screening

Pregnant or breastfeeding? Yes No

Allergy to any injectable product? Yes NoIf yes, details

On blood thinners or aspirin? Yes NoIf yes, details

Neuromuscular condition? Yes NoIf yes, details

Active infection or cold sore? Yes No

Risks and acknowledgements

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

InitialsNeurotoxin: I understand effects take days to appear and last months, and risks include bruising, headache, asymmetry, and eyelid or brow droop.

InitialsFiller: I understand risks include swelling, bruising, lumps, asymmetry, infection, and rarely, blockage of a blood vessel that may cause tissue damage or vision changes.

InitialsI understand results vary and may need touch-up.

InitialsI understand alternatives exist, including no treatment.

InitialsI have been told who to contact after treatment.

Consent

Areas to be treated

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

Signatures

Client / patient signature

Date

Practitioner name and signature

Date

Template from zdrovia.ca/templates/neurotoxin-and-filler-combined-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

Should I use separate consents instead?

Either works. Separate forms keep each product's details clear.

Where are product and lot recorded?

On the treatment chart, not the consent.

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.