Nonsurgical rhinoplasty informed consent form template

November 11, 2026 · 4 min read

Editorial illustration about a nonsurgical rhinoplasty informed consent form

Nonsurgical rhinoplasty is one of the most sensitive procedures in the HOF clinic, and the consent has to measure up. The nose has vessels that connect to the circulation of the eye, tissue that tolerates compression poorly, and a very strong aesthetic expectation from the patient. A generic form, designed for lips, does not cover it.

This template is generic, for nonsurgical rhinoplasty with hyaluronic acid. It includes no volume, technique or brand. For context, see nonsurgical rhinoplasty, the anatomy of the nose for injectables and the patient conversation in how to explain nonsurgical rhinoplasty.

When should you use this template?

After a detailed assessment and an unhurried conversation, at a visit separate from the day of the injection, whenever possible. Give the form to the patient to read at home. Signing on the treatment table is not the ideal moment for a high-risk procedure.

How do you adapt it?

What needs to be included?

Item	Reason
Goal and limits	Avoids the expectation of a surgical nose
Common risks	Swelling, bruising, asymmetry
Rare and serious risks	Necrosis, visual changes
Irregularities and nodules	May require correction
Temporary effect	Maintenance and costs
Alternatives	Including surgery and not treating
Warning signs and contact	The patient knows what to do

Nonsurgical rhinoplasty informed consent form template

Template

INFORMED CONSENT FORM: NONSURGICAL RHINOPLASTY

Patient: ________

Date of birth: ________

CPF (Brazilian taxpayer ID): ________

Responsible professional: ________

Professional board and registration number: ________

Clinic: ________

1. What the procedure is

Nonsurgical rhinoplasty consists of injecting hyaluronic acid gel at points on the nose, with the aim of changing the appearance of contour or proportion, without surgery, according to the professional's assessment. Goal discussed: ________.

2. How it is done

The injection is done with a needle or cannula, at the professional's discretion, with skin cleansing and, if indicated, anesthesia. Amount and technique are determined individually.

3. Limits of the procedure

Nonsurgical rhinoplasty does not make the nose smaller, does not correct breathing problems and does not replace surgery. The result depends on anatomy and may not reach what I imagine.

4. Duration of the effect

The effect is temporary and varies. The procedure may need to be repeated, at a cost. Touch-up policy: ________.

5. Common effects

Swelling, redness, sensitivity, bruising, a feeling of pressure and temporary asymmetry.

6. Less common risks

Lumps or irregularities; asymmetry; excess volume; product migration; infection; allergic reaction; delayed inflammatory reactions. Some events may require hyaluronidase, medication or follow-up.

7. Rare and serious risks

The nose is an area of high vascular risk. In rare cases, the product can enter or compress a vessel, interrupting circulation to the tissue, with intense pain, purplish or pale patches, wounds and tissue loss (necrosis), with permanent scarring. In very rare cases, the product can reach vessels connected to the eye, causing a serious change in vision, including permanent loss, or other serious complications. These are emergencies. I agree to notify the professional immediately if I notice any warning sign, and I know that management may include hyaluronidase and referral to an emergency service.

8. Information about my health

I have truthfully reported illnesses, allergies, medications, pregnancy or breastfeeding, previous nasal surgeries, previous materials in the face, and any other relevant condition.

9. Alternatives

Other options were presented, including surgical treatment and the option of doing nothing.

10. Aftercare and follow-up

I received written instructions, including on warning signs. Emergency contact: ________. Planned follow-up: ________.

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 time and opportunity to ask questions, understood the information and choose to have the procedure of my own free will. I may withdraw before the injection.

Place and date: ________

Signature of the patient or legal guardian: ________

Signature of the professional: ________

Witness (optional): ________

How does the clinic prepare for the worst-case scenario?

Keep the emergency kit, train the team and be clear about the referral flow. Hyaluronidase in the clinic and necrosis are topics to study before offering the procedure. Informed consent is only worth something if the patient truly understood.

Frequently asked questions

Why does the nonsurgical rhinoplasty consent form need to be more detailed?

Because the nose is an area of high vascular risk, with circulation that connects to that of the eye. The patient needs to understand the potential seriousness, the warning signs and the emergency plan before deciding.

Can the form promise a more harmonious nose?

No. The form should record the goal discussed and make clear that the result depends on anatomy and is not guaranteed. Avoid wording that sounds like a promise.

Does nonsurgical rhinoplasty replace surgery?

They are different approaches, with different indications and limits. The form should state that nonsurgical rhinoplasty does not fix every concern and that surgical alternatives exist.

Terms mentioned

Informed consent in orofacial harmonization Nonsurgical Rhinoplasty Hyaluronic acid Hyaluronidase Vascular occlusion in filler Necrosis after filler Nasal cartilages