Facial harmonization informed consent form template

November 11, 2026 · 5 min read

Editorial illustration about an informed consent form for facial harmonization

Many facial harmonization patients (HOF, orofacial harmonization in Brazil) have more than one procedure in the same stage: a little cheekbone, something in the chin, toxin in the upper face. Having four separate consent forms signed in the same minute does not always help: the patient does not read them, the professional rushes, and the consent loses its value. The umbrella consent organizes the general consent for a plan with several areas, and makes clear when each area needs its own form.

The template is generic and covers classes of materials: hyaluronic acid, botulinum toxin and biostimulators. It works together with the staged plan acknowledgment form and the written treatment plan.

When should you use this template?

At the consultation where the plan is finalized, after the assessment and medical history, before the first application. Use it together with specific forms for higher-risk areas, such as lip filler, biostimulator and nonsurgical rhinoplasty.

How do you adapt it?

List the areas and the planned materials, clearly marking what is the current stage and what is a future one.
Separate what is already covered from what needs its own form.
Include the reversal plan (hyaluronidase) and the emergency plan.
Describe the touch-up policy.
Ask for a legal review and check the rules of your professional board in Brazil (CFM, CFO or another, depending on your profession).

Which general risks should be included?

Class	Risks to mention
Dermal filler	Swelling, bruising, lumps, asymmetry, vascular complication, necrosis, visual changes (rare)
Toxin	Bruising, asymmetry, drooping eyelid or eyebrow, headache, effect different from expected
Biostimulator	Swelling, nodules, delayed inflammatory reaction, gradual and variable result
All	Infection, allergic reaction, result different from expected, need for maintenance

Facial harmonization informed consent form template

Template

INFORMED CONSENT FORM: FACIAL HARMONIZATION

Patient: ________

Date of birth: ________

CPF (Brazilian taxpayer ID): ________

Responsible professional: ________

Professional board and registration number: ________

Clinic: ________

1. What the plan is

Facial harmonization brings together procedures that aim to change the proportion, contour, volume or appearance of areas of the face, according to the professional's individual assessment. My plan includes the following areas and materials:

Area: ________ Material: ________ Stage: ________

2. How they are performed

The procedures are performed with a needle or cannula, after cleansing the skin, with or without anesthesia. The professional determines amounts and techniques individually.

3. Duration and maintenance

The effects are temporary and vary. The procedures may need to be repeated, at a cost. Touch-up policy: ________.

4. Common effects

Swelling, redness, pain or tenderness, bruising, a feeling of firmness and temporary asymmetry.

5. Less common risks

Lumps or irregularities; asymmetry; too much or too little effect; product migration; infection; allergic reaction; delayed inflammatory reactions; drooping eyelid or eyebrow and headache (with toxin). Some events may require treatment, including hyaluronidase (when the material is hyaluronic acid), medication or follow-up.

6. Rare and serious risks

In rare cases, injectable products can enter or compress blood vessels, causing intense pain, changes in skin color, wounds and tissue loss, with permanent scarring. In very rare cases, there may be a serious change in vision, including permanent loss. These are emergencies. I agree to notify the professional immediately if I notice any warning sign.

7. Procedures with their own consent form

For the procedures below, I have also signed a specific form: ________.

8. Information about my health

I have truthfully reported illnesses, allergies, medications, pregnancy or breastfeeding, active infections, and previous procedures or materials in the face.

9. Alternatives

Alternatives were presented to me, including other procedures, surgical treatments and the option of doing nothing.

10. Staged plan

I understand that the plan may be divided and changed according to my response and the professional's assessment, and that a relevant change may require a new form.

11. No guarantee of results

The result depends on individual factors and is not guaranteed. Illustrative images and simulations are only for discussing possibilities.

12. My data

I authorize the processing of my personal and health data for care and the patient chart, in accordance with the LGPD (Brazil's General Data Protection Law). Other uses of my image require separate authorization.

13. Statement

I have read this form, had the opportunity to ask questions, and choose to go ahead with the plan of my own free will. I may withdraw at any time before each application.

Place and date: ________

Signature of the patient or legal guardian: ________

Signature of the professional: ________

Witness (optional): ________

How do you avoid a form that is signed without being read?

Do not hand over a stack of papers at the last minute. Hold a structured conversation, summarize in three or four points and give the patient time. The golden rule of informed consent is understanding, and the document is only the record. For organizing the consultation, see medical history in HOF and safety and complications.

Frequently asked questions

Does an umbrella consent replace procedure-specific consents?

It organizes the general consent for the plan, but procedures with particular risk, such as the nose, tear troughs or biostimulators, usually call for specific consents. Check with your attorney and according to your professional board.

Do I need to redo the consent at every session?

When the plan changes in a relevant way (new area, new material, new stage), record an addendum or a new consent. For sessions that follow the plan, note the conversation in the patient chart.

Should the consent list the products used?

It can state the class of material. The lot and product record belongs in the patient chart and the traceability sheet.

Terms mentioned

Informed consent in orofacial harmonization Hyaluronic acid Botulinum toxin Collagen biostimulator Hyaluronidase Vascular occlusion in filler LGPD in facial harmonization