Medical Form Encrypted – 2 - Dermal Fillers, Anti-wrinkle, Skin care & Aesthetics.


Medical Questionaire

Your Consent

This is an informed consent and medical screening document that has been prepared to help inform you and your practitioner concerning your treatment and the risks involved. It is important that you read this information carefully, completely and answer each question to the best of your knowledge.

RISKS OF TREATMENT: Every procedure involves a certain amount of risk, and it is important that you understand the risks involved. An individual’s choice to undergo a procedure is based on the comparison of the risk to potential benefit.

Although the majority of patients do not experience complications, you should discuss each of them with your practitioner to make sure you understand the risks, potential complications, and consequences of your treatment:
Bleeding, Bruising/Swelling, Infection & Unsatisfactory Outcome/Temporary loss of function of nearby muscles.


  • I authorize the taking of clinical photographs and videos and that they will be kept as a medical insurance requirement.
  • I understand that photographs and video may be taken of me for educational and marketing purposes.
  • I hold the practitioner harmless for any liability resulting from this production.
  • I waive my rights to any royalties, fees and to inspect the finished production as well as advertising materials in conjunction with these photographs.
  • I undestand that I will be given the choice to opt out of use of clinical photographs and videos for use in marketing during the treatment consent process.

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