About this template
A hyaluron pen consent form is an essential tool for licensed estheticians and beauty professionals offering needle-free hyaluronic acid filler treatments. This template ensures that every client is fully educated on the procedure, potential side effects, and associated risks before undergoing treatment. By outlining specific acknowledgements—such as temporary swelling, bruising, tenderness, and rare complications like vessel blockage or asymmetry—clinics protect both their business and their clients.
Transitioning to a digital Google Form eliminates paper clutter, reduces administrative overhead, and makes client record-keeping completely seamless. Clients can easily review disclosures and complete their acknowledgements on any smartphone, tablet, or desktop before arriving at the clinic. Doc2Form helps you transform these critical liability documents into easy-to-manage digital workflows, ensuring you maintain thorough, accessible records for every appointment.
Key features
- Collect mandatory risk acknowledgements for needle-free filler treatments
- Fully customizable questions tailored to specific aesthetic procedures
- Accessible on all mobile devices for quick client completion
- Centralized digital record-keeping for better clinic organization
- Paperless workflow that saves storage space and printing costs
Use cases
- Pre-treatment consultations for lip enhancement services
- Collecting digital liability waivers prior to facial filler procedures
- Documenting client health disclosures and risk acknowledgements
- Maintaining organized digital records for aesthetic clinic compliance
What this form collects
- Full Legal Name (Short answer)Enter your first and last name as it appears on your government-issued ID.
- Phone Number (Short answer)Provide the best phone number to reach you regarding your appointment.
- Email Address (Short answer)We will send your appointment confirmation and aftercare instructions here.
- Date of Birth (Date)You must be at least 18 years of age to receive this treatment.
- Pain & Tenderness (Multiple choice)Acknowledge that mild to moderate pain or tenderness may occur in the treated area.
- Itchiness, Redness & Swelling (Multiple choice)Acknowledge that temporary inflammation, redness, and swelling are normal post-treatment responses.
- Pustules or Acne-like Bumps (Multiple choice)Acknowledge the possibility of temporary breakouts or small pustules forming near the injection site.
- Bruising & Bleeding (Multiple choice)Acknowledge that minor bruising or pinpoint bleeding may occur around the treated area.
- Infection Risk (Multiple choice)Acknowledge that any procedure breaking the skin barrier carries a baseline risk of infection.
- Blood Vessel Blockage (Multiple choice)Acknowledge the rare but serious risk of vascular occlusion or blood vessel blockage from filler placement.
- Grayish Discoloration (Multiple choice)Acknowledge the potential for temporary grayish discoloration of the skin if product is placed too superficially.
- Asymmetry or Lumps (Multiple choice)Acknowledge that uneven product settling, lumps, or minor asymmetry may occur and may require correction.
- Consent Confirmation (Multiple choice)By checking below, you confirm that you have read all disclosures, had your questions answered, and voluntarily consent to the procedure.
- Digital Signature (Short answer)Type your full legal name to serve as your electronic signature.
- Signing Date (Date)Select today's date.
FAQ
What is the purpose of a hyaluron pen consent form?
It ensures clients are fully informed about the needle-free filler procedure, understands potential risks like swelling or bruising, and formally acknowledges these factors before treatment begins.
Can I customize the risk acknowledgements in this template?
Yes. Once you convert or open this template in Google Forms, you can freely add, remove, or edit questions to match your specific clinic protocols and regional requirements.
How do clients sign the form digitally?
Clients can type their full name and submit the form electronically from any smartphone, tablet, or computer before their scheduled appointment.
Where are completed client responses stored?
All submissions are automatically organized and securely stored in your connected Google Sheets spreadsheet for easy reference and clinic record-keeping.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.