Lip Filler & Dermal Filler Consent Form

Please ensure that you have at least 15 minutes of uninterrupted focus to fill in this form accurately and correctly. All information given is strictly confidential.

I have read and understood the information found on the corresponding page of Earth & Beauty's website, and would like to proceed with the aesthetics treatment. Select all that apply. (If you are considering the other filler treatments in the future, you can preselect these now so you don't have to fill in the form again.)
If you have a health condition that may impact your suitability for this procedure and have NOT YET discussed this with Earth & Beauty, please do so before continuing with this form.
Have you ever had a bad reaction to any of the following? Select all that apply.
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Lidocaine topical anaesthetic gel will be placed under a plaster and applied to an inconspicuous area of the body. This is precautionary measure and is an optional step in having your filler treatment at Earth & Beauty.

Treatment Risks


Pre-Procedure Advice

Post-Procedure Advice

Payment Methods


Final Requirements

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