Informed consent form template for temple filler

November 11, 2026 · 5 min read

Quick facts

Document: Informed consent form
Area: Temples
Key point: Blood vessels in the area and risk of bruising
Review: A lawyer and your professional board's rules before use

The temples look like a simple area, but they have vessels and tissue planes that call for respect. The consent form for temple filler needs to record three things: the patient understood what will be done, knows that bruising is relatively common, and knows there is a rare but serious risk of a vascular complication.

The text below is generic for hyaluronic acid, with no technique or volume. For the basics of the procedure, see temple filler and the review of temporal anatomy for injectables.

When should you use this template?

At the assessment, after the medical history, with time to read. If the patient came in for a "quick consultation" and wants to be treated the same day, the consent is fragile: offer to let them read it calmly and decide later.

What must never be missing?

Item	Reason
Area and product class	Records what was consented to
Bruising and swelling	Most frequent risk in the area
Asymmetry and irregularity	May need adjustment
Vascular occlusion and necrosis	Rare, serious risk the patient must know about
Vision changes	Emergency sign that must be mentioned
Alternatives	Free consent
Medications in use	Reduces surprises and risk

Consent form template for temples

Template

INFORMED CONSENT FORM: TEMPLE FILLER WITH HYALURONIC ACID

Patient: ________

Date of birth: ________

CPF (Brazilian taxpayer ID): ________

Responsible professional: ________

Professional board and registration number: ________

Clinic: ________

1. The procedure

It consists of injecting a hyaluronic acid gel into the temple area, with the aim of restoring volume or softening the local hollowing, according to the professional's assessment. Sides to be treated: ( ) right ( ) left.

2. How it is done

The injection uses a needle or cannula, at the professional's discretion, after cleansing the skin, with or without anesthetic. The amount and technique are set at my individual assessment, in one or more stages.

3. Duration

The effect is temporary and varies from person to person. The procedure may need to be repeated, at a cost. Agreed touch-up: ________.

4. Common effects

Swelling, redness, tenderness, pain when chewing in the first few days, bruises (hematomas) and temporary asymmetry. The final result can only be judged after the swelling goes down.

5. Less common risks

Lumps or irregularities, too much or too little volume, infection, allergic reaction, delayed inflammatory reactions and product migration. Some may need treatment, including hyaluronidase, an enzyme that dissolves hyaluronic acid.

6. Rare and serious risks

The area contains important blood vessels. In rare cases, the product can enter or compress a vessel and cut off circulation, causing severe pain, pallor or purplish patches, a wound and tissue loss (necrosis), with possible scarring. In very rare cases, vessels connected to the eye can be affected, causing serious vision changes, including permanent loss. These are emergencies. I will tell the professional immediately if I notice any warning sign.

7. My health and medications

I have truthfully reported my illnesses, allergies, medications (including blood thinners and antiplatelet drugs), supplements, pregnancy or breastfeeding, and previous facial procedures.

8. Alternatives

Other options were presented to me, including not treating at all. 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 depends on individual factors and cannot be guaranteed. Simulations 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 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 explain bruising without downplaying it?

Say that a bruise is possible, that it usually clears on its own within a few days, and that it can take longer in people who take certain medications. Agree in advance on what to do if one appears, and make clear that severe pain, pale skin or a change in vision are not "a bruise": they are reasons to call right away.

General aftercare is covered in post-procedure instructions, and reversal in hyaluronidase in the office. See also safety and complications.

Frequently asked questions

What should a temple consent form include that others do not?

It names the area, the risk of bruising because of the vessels in the region, and the rare risk of a vascular complication. It should also state that the result depends on assessment and is not guaranteed.

Do I need to discuss blood thinners and supplements?

Yes, it is worth asking about them in the medical history and recording the answer. Some medications and supplements raise the chance of bruising, and the patient should talk to whoever prescribed them and never stop them on their own.

Can the form be digital?

It can, as long as the record is stored securely and the patient has read and understood it. Check the rules of your professional board and the data protection rules.

Terms mentioned

Hyaluronic acid Informed consent in orofacial harmonization Hyaluronidase Vascular occlusion in filler Necrosis after filler Swelling after harmonization Hematoma After Filler