Injectable Consent Form

Medical History

Are you currently under a physician’s care for any medical condition? 

Are you taking any medications (prescription or over-the-counter)?

Do you have any allergies (medications, foods, etc.)?

Have you had any previous reactions to injections?

Are you pregnant, trying to become pregnant, or breastfeeding?

Acknowledgement and Consent

I acknowledge that I have been informed about the nature of the injection procedure, including the potential risks and benefits.

I understand that no procedure is without risks, and possible side effects may include but are not limited to infection, swelling, bruising, and allergic reactions.

I have had the opportunity to ask questions and discuss any concerns with the practitioner.

I understand that multiple treatments may be necessary to achieve the desired results and that results may vary.

I agree to follow all post-procedure care instructions provided by the practitioner.

I consent to the administration of the injectable procedure by the named practitioner.

Practitioner Declaration

I have discussed the procedure and the associated risks with the client. I believe the client understands and consents to the procedure.