Know the boundaries
Not for: Permanent fillers, biostimulatory fillers, silicone, body contouring, or a promise that filler is fully reversible.
Source-checked educational draft, version 1.0, September 20, 2026. Not reviewed or approved by an attorney or clinician. A qualified professional must adapt and approve it for the practice, jurisdiction, patient and actual service before use. A signature does not replace an informed discussion. Adult templates only; not a minor or proxy-consent workflow.
Inside the template
Five pages: practice preparation, patient discussion, two completion pages, and an implementation/source appendix. The PDF has fillable text fields; use the Word version to revise the language. Typed fields are not a verified electronic-signature service.
Actual sample page · Open to enlarge · Full editable files available below
Prepare your practice version
- Attach the patient labeling for the exact product and check the planned anatomical site.
- Explain common effects and serious vascular complications.
- Record previous filler, allergies, medicines and individualized risks.
- Document the urgent assessment route and discuss the limits and risks of any corrective treatment.
Public text preview
Language for the conversation
Proposed treatment
The clinician will identify the hyaluronic acid filler, location and intended change below. The discussion must address the actual product and whether the proposed use matches its labeling.
Risks to discuss
Swelling, bruising, redness, tenderness, itching and pain can occur. Other risks include infection, lumps, inflammatory reactions, allergy and unsatisfactory appearance. Accidental injection into a blood vessel can cause tissue death, blindness or stroke; injury may be permanent. Some complications can develop later.
Correction is not guaranteed
Further procedures may be needed for complications or unwanted results and have their own risks. Do not assume an HA filler can always be completely or easily removed. Any proposed dissolving treatment requires its own assessment and discussion.
Details to complete before signing
- Patient name
- Practice / treating clinician
- Exact product or device and treatment area
- Treatment goal and anticipated benefit
- Labeling / patient information version supplied
- Patient-specific risks and relevant history reviewed
- Alternatives discussed, including no treatment
- Questions and answers / additional agreed limits
- Aftercare instructions and follow-up plan reference
- Practice urgent contact / after-hours route
- Patient signature and date / time
- Clinician signature and date / time
- Copy supplied: date / method
Common questions
Is this a consent for every dermal filler?
No. Its scope is hyaluronic acid fillers. The treating clinician must add the specific product labeling, site risks and patient factors. Other filler materials need a different review.
Does the form waive responsibility for complications?
No. It records a discussion and voluntary decision; it is not a liability waiver or guarantee of an outcome.