Online Lip Dermal Fillers Form

Name *

Surname *

Address *

Postcode *

Date of Birth *

Contact Number

Email

Have you or anyone in your household had COVID-19? *

Yes
No

Do you have or have you had a high temperature in the last 7 days? *

Yes
No

Please select the treatment you require an appointment for *

If you treatment is not in the list, please call the clinic

Have you previously been treated with Dermal Fillers/PDO threads ? *

Yes
No

Dermal / Threads Information

Are you pregnant, breast feeding or trying to conceive (LMP) ? *

Yes
No

Any allergies/ had allergic reaction ? *

Yes
No

Any localized infection/cold sores? *

Yes
No

Infections and/or Sores information

Please enter details in regards to localized infections and/or sores

Do you suffer from any other medical conditions? *

Yes
No

Medical Condition Information

Please list all medical conditions where possible

Suffer from CNS disease, neurological disorder, including migraine or epilepsy? *

Yes
No

Head symptoms Information

Please list symptoms here

Take any other medication (incl. over the counter or herbal medicines)? *

Yes
No

Medication Information

Have you taken Aspirin/NSAIDs/Clopidogrel/Warfarin /Antibiotics recently? *

Yes
No

Do you consent to photos being taken before and after treatment? *

Yes
No

Lip Dermal Fillers

THE FOLLOWING POTENTIAL ADVERSE EVENTS HAVE BEEN FULLY EXPLAINED AND UNDERSTOOD BY ME:
Possible side effects may include redness, swelling (that can last for 2-3 days), bleeding, bruising, pain, itching, infection, discoloration, hypersensitivity and acne form papules at injection site. Extreemly rare reports of blindness have been reported. The proportionate risk has been explained to me. I will advise my Practitioner should I experience any of the aforementioned adverse events and that I have made aware of any upcoming events that these side effects may have an impact on.
I am aware that these non-permanent dermal fillers are sterile gels containing non-animal hyaluronic acid and are designed to fill and enhance the lip as agreed with my Practioner. I understand that more than one treatment session may be required to obtain maximum effects and no guarantee can be given as to the results of the treatment referred to in this document. I accept and understand that the goal of this treatment is improvement not perfection.
I confirm that to the best of my knowledge that the information that I have supplied is correct and that there are no other medical information that I need to disclose.
I consent to treatment with Hyaluronic Dermal Fillers as discussed with my Practioner. I understand the information given and any questions or queries I have have been answered. Any medical terminology used in this consent has been explained to me. I am aware of all the risks that are associated with the procedure I will be undertaking. I am aware there are alternative treatments and that to have no treatment is one of those options.
I give permission that any prescription issued by KAMA on behalf of the client will be kept by KAMA in anticipation of treatment. All client information is kept in compliance with the Data Protection Act. (2018)

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