Informed consent form template for masseter botulinum toxin

November 11, 2026 · 4 min read

Quick facts

Document: Informed consent form
Procedure: Botulinum toxin in the masseter
Key point: Effect on chewing and on the smile, and that the effect is temporary
Review: A lawyer and your professional board's rules before use

Botulinum toxin in the masseter is requested by people who are concerned about a wider lower face or about bruxism, and each reason changes the conversation. The consent form needs to record the indication, what the patient should expect with chewing, that the effect is temporary and that the result is not guaranteed.

The template is generic and includes no dose or technique. For the clinical reasoning, see botulinum toxin in the masseter, and for the product, the glossary entry on botulinum toxin.

When should you use this template?

At the assessment, after the medical history. Ask about neuromuscular diseases, medications that affect the neuromuscular junction, pregnancy, breastfeeding and allergies, and record the answers.

What must never be missing?

Item	Reason
Indication and area	Defines what was consented to
Temporary effect	Avoids the idea of a permanent result
Gradual effect	The result is not immediate
Weaker chewing or fatigue	Expected effect in some patients
Smile or contour asymmetry	Known risk
Bruising, local pain, headache	Possible local effects
Alternatives and the option not to treat	Free consent

Consent form template for masseter botulinum toxin

Template

INFORMED CONSENT FORM: BOTULINUM TOXIN IN THE MASSETER

Patient: ________

Date of birth: ________

CPF (Brazilian taxpayer ID): ________

Responsible professional: ________

Professional board and registration number: ________

Clinic: ________

1. The procedure

It consists of injecting botulinum toxin into the masseter muscles, with the aim of reducing the contraction strength of these muscles, which may soften the volume of the lower face or reduce symptoms related to teeth grinding, according to the professional's assessment. Indication: ( ) aesthetic ( ) bruxism ( ) both.

2. How it is done

The treatment is given as injections with a fine needle, at the professional's discretion. The amount and injection points are set at my individual assessment. There may be mild discomfort at the time.

3. Duration and onset of the effect

The effect is not immediate and usually takes a few days to appear. The change in contour, when it happens, is gradual. The effect is temporary and tends to fade over time, so new sessions may be needed, at a cost. Agreed touch-up: ________.

4. Expected effects

There may be a reduction in bite strength and a feeling of tiredness or difficulty chewing harder foods during the first weeks. This is an effect of the treatment itself.

5. Possible effects and risks

Local pain or tenderness, small bruises, swelling, headache, smile or contour asymmetry, insufficient or excessive result, allergic reaction and, in rare cases, spread of the toxin to neighboring muscles. In very rare cases, systemic effects may occur and require immediate medical care.

6. My health

I have truthfully reported my illnesses, especially neuromuscular ones, allergies, medications in use, pregnancy or breastfeeding, and previous facial procedures.

7. Alternatives

Other options were presented to me, including other treatments, dental follow-up and the option not to treat. I freely choose this one.

8. Aftercare and follow-up

I received written instructions on aftercare and warning signs. Contact: ________. Planned follow-up: ________.

9. No guarantee of results

I understand that the result depends on individual factors and cannot be guaranteed. Illustrative images or simulations are only for discussing possibilities.

10. 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.

11. Declaration

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

Place and date: ________

Patient or legal guardian signature: ________

Professional signature: ________

How do you align contour expectations?

Patients who want a slimmer contour need to hear that the change, when it happens, is gradual and that facial volume also depends on bone, fat and skin. When the concern is really a double chin or soft tissue, toxin may not be the answer. See how to think through the choice in buccal fat removal or masseter toxin.

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

Frequently asked questions

Does masseter toxin need a different form from glabella toxin?

The core is similar, but the masseter has its own points: the effect on chewing strength, possible smile asymmetry and a gradual change in contour. They are worth mentioning.

Do I need to warn that the effect is not immediate?

Yes. The effect usually takes a few days to appear, and contour changes take longer. Recording this avoids complaints caused by wrong expectations.

Does the form need to name the toxin brand?

There is no need to name a commercial brand in the public text. The medical record should note the product used, the lot and the expiration date, according to your professional board's rules.

Terms mentioned

Botulinum toxin Informed consent in orofacial harmonization Botulinum toxin unit Facial asymmetry Swelling after harmonization Hematoma After Filler