DERMAL FILLER CONSULTATION & CONSENT FORM

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Date of Birth

Contact Number

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Emergency Contact Name

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TREATMENT OVERVIEW

Dermal fillers are injectable hyaluronic acid-based gels used to restore volume, soften lines, and enhance facial contours. Common areas include lips, cheeks, nasolabial folds, jawline, and chin. Effects typically last 6–18 months depending on product and area treated.

MEDICAL HISTORY

Please tick all that apply:

Pregnancy or breastfeeding Autoimmune or collagen vascular disease (e.g. lupus, RA) Blood clotting disorders or current anticoagulant use Allergy to lidocaine, hyaluronic acid, or bee stings Herpes simplex (cold sores) history Recent dental work, infection, or sinus issues Active acne, infection, eczema, or skin disorder in treatment area Recent vaccinations (within 2 weeks) History of keloid scarring or delayed healing History of anaphylaxis Previous dermal fillers or cosmetic procedures (within 4 weeks) Recent use of Roaccutane / isotretinoin (within 12 months) None of the above

Please list any medications, allergies, or other health concerns:

Previous cosmetic treatments

TREATMENT PLAN

Please select the treatment(s) you'd like to proceed with today:

Target Areas (Botox)

1 Area – £179 2 Areas – £229 3 Areas – £279 Lip Flip – £149 Gummy Smile – £149 Master Muscle / Jaw Slimming – £249 Neck Lift – £299

Treatment Areas(Dermal Fillers)

Lip Enhancement – 0.5ml (£130) Lip Enhancement – 1ml (£180) Nasolabial Lines (Nose to Mouth) – from £180 Marionette Lines (Mouth to Chin) – from £180 Chin Enhancement – from £180 Cheek Enhancement – from £200 Jawline Contouring – from £200

Treatment Areas (Profhilo)

5-Point Face Lift (2-part treatment) – £450 Hand Rejuvenation – £240 Neck Rejuvenation – £450

Treatment Areas (Aqualyx Fat Dissolving Injectables)

Double Chin / Session – £150 Small Body Area (e.g. love handles, bingo wings) – from £150 Large Body Area (e.g. abdomen, back fat) – from £250

RISKS & SIDE EFFECTS

Please confirm your understanding by checking each box:

I understand that dermal filler injections involve the use of a hyaluronic acid-based gel to enhance or restore volume in specific facial areas. I acknowledge that common side effects may include redness, swelling, tenderness, itching, bruising, or lumps at the injection site. I understand that swelling may be more pronounced in areas such as the lips. I am aware of the rare but serious risk of vascular occlusion, which may require emergency intervention to prevent tissue damage. I understand that results are not permanent and typically last between 6 and 18 months. I have been advised to avoid touching, massaging, or applying makeup to the area for 12 hours post-treatment. I understand that QT Beauty & Aesthetics may use hyaluronidase (an enzyme that dissolves filler) if adverse reactions or undesired outcomes occur. I have been offered the opportunity to ask questions and fully understand the procedure and risks.

AFTERCARE ADVICE

I confirm that I will follow the post-treatment guidance below:

Avoid alcohol, aspirin, ibuprofen, or exercise for 24 hours. Do not touch, press, or massage treated areas for at least 12 hours. Avoid heat (e.g. saunas, hot showers), sunbeds, and intense sun exposure for 48–72 hours. Use a cold compress for 10-minute intervals to reduce swelling (if needed). I understand I must notify QT Beauty immediately if I notice excessive pain, blanching (white skin), or discolouration.

PHOTO/VIDEO CONSENT (OPTIONAL)

Please select your preference below:

I consent to before and after photographs being taken for my treatment records. I consent to QT Beauty & Aesthetics using my photographs for marketing purposes (e.g., website, social media). I do not consent to any photographs being taken or used.

CLIENT DECLARATION & CONSENT

Please confirm each item by ticking the boxes:

I confirm that all medical and personal information I have provided is complete and accurate. I understand the procedure, risks, side effects, and aftercare advice. I acknowledge that no guarantees can be made regarding results or longevity. I understand that follow-up or correctional appointments may be required. I voluntarily consent to receive dermal filler treatment at QT Beauty & Aesthetics. I confirm that I am over 18 years of age and not under the influence of alcohol or drugs.

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019-9253-8866
info@qtbeautyandaesthetic.co.uk
31 Fore St, Hertford Hertfordshire SG14 1DJ

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