Informed Consent for Botulinum Toxin and Dermal Filler Treatment

Procedure Name

Form Sections

Section 1info grid

Clinic or Practice Name

Treating Provider

Patient Full Legal Name

Date of Birth

Date of Treatment

Treatment Areas Planned

Product Name and Brand

Units or Volume Injected

Section 2text block

Section 3list block

Section 4text block

Section 5list block

Section 6list block

Section 7text block

Section 8text block

Section 9text block

Section 10list block

Section 11text block

Section 12text block

Section 13text block

Section 14text block

Section 15text block

Section 16text block

Section 17signature block

Patient Signature

Parent or Guardian Signature (if patient is under 18)

Treating Provider Signature

Witness Signature

Date and Time of Consent

Informed Consent for Botulinum Toxin and Dermal Filler Treatment

Patient and Provider Information

Clinic or Practice Name

Treating Provider

Patient Full Legal Name

Date of Birth

Date of Treatment

Treatment Areas Planned

Product Name and Brand

Units or Volume Injected

What This Document Covers

This document is a structured administrative consent layout for botulinum toxin treatments (brand names include Botox, Dysport, and Xeomin) and dermal filler treatments (gel substances injected under the skin to add volume, brand names include Juvederm, Restylane, and Sculptra). It records the patient's agreement to receive these treatments, documents which areas are treated and which products are used, and captures the provider's disclosures about what to expect. Signing this form means the patient understands the treatment plan and its limits, not that any specific result is guaranteed.

Pre-Treatment Health Screening

[ ] I am NOT pregnant or breastfeeding. Botulinum toxin and most fillers have not been tested in pregnancy and are not approved for use during pregnancy or breastfeeding.

[ ] I do NOT have a known allergy to botulinum toxin, hyaluronic acid, lidocaine, or any ingredient in the planned product. I have reviewed the product ingredient list with my provider.

[ ] I do NOT have an active skin infection, open wound, rash, or cold sore in or near the planned treatment area.

[ ] I have told my provider about ALL current medications, including blood thinners such as aspirin, warfarin, and ibuprofen, and any herbal supplements such as fish oil, vitamin E, or ginkgo.

[ ] I have disclosed all previous filler treatments, including product types and dates, and any side effects or complications from past treatments.

[ ] I have disclosed any history of autoimmune disease, bleeding disorders, keloid scarring, or cold sore outbreaks, as these may affect my suitability for treatment.

How the Treatment Works

Botulinum toxin is injected in tiny amounts into specific facial muscles using a very fine needle. It works by temporarily reducing muscle movement in the treated area. This smooths lines caused by repeated expressions such as frowning or squinting. Results usually appear within 3 to 14 days and last 3 to 6 months. Dermal fillers are gel-like substances injected under the skin to add volume, soften lines, or reshape facial features such as lips and cheeks. The provider will mark the injection points on the skin and may apply a topical numbing cream or ice to reduce discomfort. The total appointment time is usually 30 to 60 minutes depending on the number of areas treated.

Risks and Possible Side Effects

Common injection site reactions: redness, swelling, bruising, and tenderness at injection sites. These are temporary and usually resolve within 24 to 72 hours. Swelling from fillers may last up to 2 weeks.

Headache: mild headache is occasionally reported after botulinum toxin injections and typically resolves within 24 to 48 hours.

Asymmetry: the face may look slightly uneven after treatment. In most cases this can be corrected at a follow-up appointment. Full symmetry cannot be guaranteed because of natural differences between the two sides of the face.

Unintended muscle weakness: botulinum toxin may spread slightly beyond the intended injection point, causing temporary drooping of an eyelid, eyebrow, or corner of the mouth. This is temporary and resolves as the product wears off, usually within 4 to 12 weeks.

Filler migration: injected filler material may occasionally shift from the original treatment area over time, especially in high-movement zones. This may require additional treatment to correct.

Allergic reaction: rare but possible. Symptoms may include hives, itching, rash, or in very rare cases a more severe reaction. Staff are trained to manage allergic reactions and emergency equipment is available on site.

Vascular occlusion (filler only): in rare cases, filler injected near a blood vessel can compress or enter the vessel, reducing blood supply to nearby skin or, in extremely rare cases, affecting vision. This is the most serious known risk of filler treatment. The provider uses aspiration technique and low injection pressure to reduce this risk. Hyaluronidase, an enzyme that dissolves hyaluronic acid fillers, is kept on site for emergency use.

Infection: bacteria can enter any injection site. Sterile technique is used during the procedure. Patients should avoid touching treated areas for 24 hours and should contact the clinic immediately if they notice unusual warmth, pain, pus, or spreading redness.

Nodule formation: small firm lumps may form under the skin, especially with fillers. Most dissolve on their own. Some may need to be massaged or dissolved with hyaluronidase.

Results not guaranteed: individual response to treatment varies. The provider cannot guarantee any specific outcome. Results may differ from what was discussed or shown in reference photos.

Other Options to Consider

Topical skincare products: retinoids, vitamin C serums, and daily SPF protection can slow the appearance of lines over time but do not provide the immediate results of injectable treatment.

Energy-based treatments: radiofrequency, microfocused ultrasound, and laser resurfacing can tighten skin and reduce lines without injections.

Surgical options: brow lifts, facelifts, and lip augmentation surgery provide longer-lasting results but carry higher risks and longer recovery times.

No treatment: choosing not to proceed is always an option. Declining will not affect access to other care at this clinic.

What Results to Expect

Botulinum toxin treatments can reduce the appearance of expression lines by 60 to 90 percent in responsive patients. Dermal fillers can restore volume and smooth lines soon after injection. Neither treatment permanently stops the aging process. Results depend on individual factors including skin quality, muscle strength, metabolism, sun damage history, and habits such as smoking and sun exposure. Maintenance treatments are needed to sustain results. Reference photos shown during consultation are for illustration only and do not represent a guaranteed outcome for this patient.

Post-Treatment Care Requirements

To reduce the chance of side effects, the patient agrees to follow these steps after treatment: (1) Do not rub, press on, or massage the treated area for at least 4 hours after botulinum toxin injections and for 24 hours after filler injections. (2) Stay upright for at least 4 hours after botulinum toxin injections. (3) Avoid strenuous exercise, saunas, hot tubs, and alcohol for 24 hours. (4) Avoid direct sun exposure and tanning beds for at least 2 weeks. (5) Do not apply makeup or products with active ingredients such as retinoids or acids to treated areas for 24 hours. (6) Call the clinic right away if you notice unusual pain, skin color changes, vision changes, or signs of infection.

Follow-Up and Touch-Up Policy

A follow-up appointment is offered [Provider to specify: e.g. 2 weeks after botulinum toxin treatment / 4 weeks after filler treatment] to check results and make minor adjustments if needed. Touch-up injections during this visit are included only if the original treatment plan was followed correctly and post-care instructions were observed. Touch-ups outside this window, corrections the patient considers insufficient, or adjustments needed because post-care instructions were not followed are billed separately. Refunds are not offered for cosmetic injectable services once the product has been administered, as the provider's time and materials have been used.

Photography and Clinical Documentation

[ ] I agree to allow the clinic to take clinical photographs of my treatment areas before, during, and after the procedure for my medical record only.

[ ] I agree to allow the clinic to use my de-identified before-and-after photographs for internal training and quality review.

[ ] I agree to allow the clinic to share my before-and-after photographs on its social media, website, or marketing materials. My name will not be used without separate written consent.

[ ] I do NOT agree to any use of my images beyond my personal medical record.

Payment Policy

Injectable aesthetic treatments are elective cosmetic procedures and are not covered by health insurance. Full payment is due at the time of service. Refunds are not provided once the product has been administered. If a complication is directly caused by the provider's technique, corrective treatment will be provided at no charge. This does not cover natural variation in results, temporary side effects, or outcomes that differ from patient expectations.

Right to Refuse or Stop Treatment

The patient has the right to refuse this treatment or to ask the provider to stop at any point during the procedure. Refusing will not affect the patient's access to other care at this clinic. If the patient asks the provider to stop mid-procedure, the patient is responsible for payment for the portion already completed and for any materials already opened or used.

Patient Understanding

I confirm that I have read this consent form, or it has been read to me in a language I understand. I have had the chance to ask questions about the treatment plan, the products used, the risks, and what results I can expect. All my questions have been answered to my satisfaction. I understand that cosmetic results cannot be guaranteed and that the aging process continues after treatment.

Language Access

If English is not your main language, please ask for an interpreter before signing. This form must be fully understood before you agree to treatment. The clinic can arrange for a qualified interpreter or a translated version of this document.

Copy of Consent

I acknowledge that I have been offered a copy of this signed consent form for my own records. I may request an additional copy at any time from the clinic.

Patient Authorization

I voluntarily agree to receive the botulinum toxin and/or dermal filler treatment described in this form. I confirm that I have disclosed all relevant medical history, medications, and allergies. I agree to follow the post-care instructions provided. I understand the risks and limitations of this treatment and accept them as part of my decision to proceed.

Signatures and Verification

Patient Signature

Parent or Guardian Signature (if patient is under 18)

Treating Provider Signature

Witness Signature

Date and Time of Consent

Document ID: CC-PENDING

CONSENTCOLLECT