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Dermal Filler Consent Form -Form Fill
Section One
Q1
Name
First Name
Q2
Name
Last Name
Q3
Date of Birth
Date
Q4
Phone Number
Q5
Email
Q6
Are you currently taking any medication?
Yes
No
Q7
Please, specify
Q8
As far as you know do you have any allergies?
Yes
No
Q9
Have you had any treatment with dermal fillers before such as absorbable dermal fillers, semi permanent dermal fillers, or botulinum toxin?
Q10
Are you pregnant or breast feeding?
Yes
No
Q11
Please select if you you suffer from any of the conditions listed below
Q12
I agree with the following statements:
Q13
Date
Date
Q14
Sign
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