Informed consent form template for double chin treatment

November 11, 2026 · 4 min read

Quick facts

Document: Informed consent form
Area: Double chin (submental area)
Key point: Treatment varies with the cause, and the form must say which one was chosen
Review: A lawyer and your professional board's rules before use

A double chin is a concern with different causes: submental fat, skin laxity, and the position of the bone and neck. Treatment varies with the cause, and the consent form needs to say which one was chosen, with its own risks. A form that is too generic leaves the patient unsure of what they agreed to.

This template has fields to tick the technique and risk passages for each one. Delete what does not apply before printing. For the assessment, see double chin: assessment, and for the technology consent, the microfocused ultrasound template.

When should you use this template?

After assessing the cause and discussing the options. If the assessment shows the concern is mostly skin laxity or structure, record that and discuss alternatives before any decision.

What must never be missing?

Item	Reason
Cause assessed	Defines whether the treatment makes sense
Technique ticked	Each one has its own risks
Swelling, pain, bruising	Common and sometimes prolonged
Irregularities, asymmetry, nodules	May appear
Injury to neighboring structures	Rare risk that must be stated
Sessions and maintenance	Avoids the idea of a one-time treatment
Alternatives	Free consent

Consent form template for double chin treatment

Template

INFORMED CONSENT FORM: TREATMENT OF THE SUBMENTAL AREA (DOUBLE CHIN)

Patient: ________

Date of birth: ________

CPF (Brazilian taxpayer ID): ________

Responsible professional: ________

Professional board and registration number: ________

Clinic: ________

1. What the treatment is

It aims to improve the appearance of the area under the chin, known as the double chin, according to the professional's assessment. Technique chosen (tick the one that applies): ( ) injectable to reduce localized fat ( ) ultrasound or heat technology ( ) biostimulator ( ) other: ________.

2. Assessment and limits

I know that a double chin can have different causes, such as fat, skin laxity and jaw position, and that the chosen treatment may not resolve all of them. I understand that more than one session may be needed and that the result varies from person to person.

3. Common effects

Swelling, which can be significant and last days or weeks depending on the technique, pain or burning, redness, local warmth, bruising, and areas that are hardened or numb for some time.

4. Less common risks

Irregularities, asymmetry, lumps, insufficient result, infection, allergic reaction and changes in sensation. With injectable procedures, nerves that move the corner of the mouth may be injured, usually temporarily, but improvement can take months. With heat-based technologies, there may be burns, blisters or changes in skin color.

5. Rare risks

Skin necrosis, difficulty swallowing and lasting changes in sensation or movement, which may require specific treatment.

6. Duration and maintenance

The effect may not be permanent and depends on lifestyle, weight gain and aging. Agreed follow-up and touch-up: ________.

7. My health

I have truthfully reported my illnesses, allergies, medications, pregnancy or breastfeeding, previous surgeries and implants in the area.

8. Alternatives

Other options were presented to me, including surgical procedures and the option not to treat. I freely choose this one.

9. Aftercare and follow-up

I received written instructions and know how to reach the professional: ________. Planned follow-up: ________.

10. No guarantee of results

I understand that the result cannot be guaranteed. Simulations and illustrative images are only for discussing possibilities.

11. My data

I authorize the processing of my personal and health data for my care and medical record, in accordance with the LGPD (Brazil's General Data Protection Law). Using my images for other purposes requires separate authorization.

12. Declaration

I have read this form, or it was read to me, and my questions were answered. I decide to have the treatment of my own free will and I may withdraw before it begins.

Place and date: ________

Patient or legal guardian signature: ________

Professional signature: ________

How do you explain that the cause changes the treatment?

Show the patient the difference between fat you can pinch between your fingers and skin that sags without fat volume. In the first case, the conversation goes one way; in the second, another. See also explaining the double chin to the patient and risks of double chin liposuction.

Keep the signed copy according to the guidance on medical record documentation.

Frequently asked questions

Does a single form work for any double chin treatment?

Only if it lists the technique chosen and its risks. Because a double chin can come from fat, skin or the position of the bone, and treatments differ, the form should be ticked by technique.

Does the patient need to know it may not resolve?

Yes. When the cause is skin laxity or bone structure, a fat treatment may not be enough, and the patient needs to hear that before signing.

Do I need to warn about prolonged swelling?

Yes. Depending on the technique, swelling can last longer than the patient expects, and warning them beforehand avoids the feeling that something went wrong.

Terms mentioned

Double chin Informed consent in orofacial harmonization Swelling after harmonization Hematoma After Filler Nodule after filler Facial asymmetry