Consents & releases 2 signers 2 pages 16 blanks to fill in

Injectable Treatment Consent Form (Neuromodulators and Fillers)

A clear consent for anti-wrinkle injections and fillers: what to expect, what can go wrong, which signs mean call us now, and who is doing the injecting.

Use this template — free See the agreement Signers don’t need an account
Injectable treatment consent
The blanks in brackets are what you fill in. FileIt adds each signer’s signature and date boxes.
Injectable treatment consent — page 1 of 2
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Injectable treatment consent — page 2 of 2
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Use this template Fill in the blanks, name who signs, and send — from FileIt eSignature.

What is a injectable treatment consent?

Cosmetic injectables are quick to give but carry real risks, and clients often arrive with expectations set by social media. A good consent form explains how long results really last, names the rare but serious complications, and makes sure the client knows exactly which symptoms need urgent attention.

This form records the clinic, the practitioner's profession and licence, and a separate prescriber if there is one. It covers the client and date of birth, the treatment (a neuromodulator, a hyaluronic acid filler, or both), the product, areas, planned dose and any review appointment and cost. It explains expected results and how long they last, says results are not guaranteed and that some uses may be off-label, and lists common, product-specific and rare risks, including spread of effect and vascular occlusion with its warning signs. It records health screening, medicines and allergies, gives aftercare, sets how photos are used, with full-face photos needing separate consent, and confirms the client had time to decide and can withdraw.

Best for
Med spas, aesthetic clinics, dermatology and dental practices offering injectables
Signed by
The client and the treating practitioner
Treatments
Neuromodulator, hyaluronic acid filler, or both
Length
2 to 3 pages

When to use a injectable treatment consent

  • A first neuromodulator treatment for frown lines and forehead
  • Lip or cheek filler with a two-week review
  • A combined appointment for both a neuromodulator and filler
  • Nurse injectors working under a medical director's prescription
  • Clinics that share anonymised before-and-after photos

What you fill in

16 blanks, then the name and email of each person who signs: client, practitioner.

1 The clinic

  • Clinic name*
  • Practitioner's name*
  • Practitioner's profession and licence*
  • Prescriber, if different from the practitioner (optional)

2 The client

  • Client's full name*
  • Client's date of birth*

3 The treatment

  • Type of treatment* a neuromodulator (botulinum toxin) · a hyaluronic acid dermal filler · a neuromodulator and a hyaluronic acid dermal filler
  • Product name (optional)
  • Treatment areas*
  • Planned dose or volume (optional)
  • Review appointment
  • Currency
  • Cost (optional)

4 Health

  • Medicines and supplements the client takes
  • Allergies

5 Photos

  • Photos* for the client's record only · for the client's record, and anonymised for training and marketing · none

6 Who signs

  • Client signature and date · An adult client. Cosmetic injectables are generally not offered to under-18s.
  • Practitioner signature and date, job title · The licensed practitioner who assesses the client and gives the treatment.

What the injectable treatment consent covers

  1. The treatment and expected results
  2. Risks and side effects
  3. Health screening
  4. Aftercare
  5. Photos and records
  6. Consent

Using the injectable treatment consent, step by step

1 Clinic and practitioner

Your clinic name fills in from your account. Add the practitioner, their profession and licence number, and the prescriber if someone else prescribes.

2 The treatment

Enter the client and date of birth, choose the treatment type, and add the product, areas, planned dose, review appointment and cost.

3 Health and photos

Record medicines, supplements and allergies from the consultation, and choose how photos may be used.

4 Sign at the consultation

The client signs on a tablet or their phone before treatment and you countersign. The consent is filed in your FileIt vault alongside the treatment notes.

Tips before you send it

  • Check local rules on who may prescribe and inject these products, and on any cooling-off period between consultation and treatment.
  • Record the product, batch number and dose in the clinical notes for every treatment.
  • Keep hyaluronidase and an emergency protocol on site whenever you inject filler.
  • Give clients the urgent warning signs in writing to take home.

Sign it online in minutes

  1. Fill in the blanks. Names, dates and amounts go straight into the agreement — the preview shows exactly where.
  2. Name who signs. Tick “This is me” for your own part. FileIt builds the PDF with every signature, date box on the right line, and you can check or move anything before sending.
  3. Send it. Each signer gets a secure link and signs from any device — no account needed. The signed PDF, with an audit trail and a Certificate of Completion, is filed in your vault and emailed to everyone.
Use the injectable treatment consent template — it’s free

Injectable treatment consent: frequently asked questions

Does the form mention vascular occlusion?

Yes. It explains that filler can rarely block a blood vessel, which can damage skin and very rarely affect vision, and lists the warning signs that need treatment straight away.

Can I use it for neuromodulator and filler in one visit?

Yes. Choose the combined option. The results and risks sections cover both products.

Does it promise how long results last?

No. It gives typical timeframes in general terms and says results vary and are not guaranteed.

Can full-face photos be used in marketing?

Only with the client's separate consent. The anonymised marketing option excludes full-face photos unless the client agrees separately.

Use this template — free