The under-eye area is thin, mobile and highly visible. Any irregularity shows, swelling can last longer than in other areas, and the patient's expectations tend to be higher than what the procedure delivers. That is why the consent form for under-eye treatment needs to be honest about its limits.
This template is generic for hyaluronic acid and includes no technique or volume. For the assessment, see dark circles: types and assessment , and for the procedure, under-eye filler .
When should you use this template?
After classifying the dark circles and discussing what each cause allows. If the main cause is pigment or vascular, filler may not solve it, and the form should record that the patient was told so.
Before signing
Type of dark circle assessed and recorded
Patient knows the skin color may not change
Tyndall effect and prolonged swelling explained
Rare vascular risk explained, with warning signs
Allergies and medications reviewed
Touch-up and cost agreed
Copy given to the patient
What must never be missing?
Item
Reason
Cause assessed and indication
Avoids the expectation of a cure
Swelling that may last
The patient worries if not warned
Tyndall effect
A bluish tone is typical of the area
Irregularities and asymmetry
Show more on thin skin
Vascular occlusion and vision changes
Rare and serious, must be stated
Alternatives
Free consent
The under-eye area is a high-risk region, and the decision to treat or not belongs to the qualified professional. If the assessment does not point to filler, record the recommendation of other approaches and do not give in to pressure from the patient.
Consent form template for under-eye treatment
INFORMED CONSENT FORM: UNDER-EYE TREATMENT 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 area below the eyes, with the aim of softening the shadow caused by the step between the eyelid and the cheek, according to the professional's assessment.
2. Limits of the treatment
I know that dark circles can have several causes, such as shadow from volume loss, pigmentation and vessels, and that filler works mainly on volume. I understand that the skin color may not change and that the treatment may not be indicated or sufficient in my case.
3. How it is done
The injection uses a needle or cannula, at the professional's discretion, after cleansing the skin. The amount and technique are set at my individual assessment.
4. Duration
The effect is temporary and varies from person to person. The procedure may need to be repeated, at a cost. Agreed touch-up: ________.
5. Common effects
Swelling, which may last longer in this area, redness, tenderness and bruising. The final result can only be judged after the swelling goes down.
6. Less common risks
A bluish tone under the skin (Tyndall effect), lumps or irregularities, asymmetry, fluid buildup, infection, allergic reaction and delayed inflammatory reactions. Some may need treatment, including hyaluronidase, an enzyme that dissolves hyaluronic acid.
7. Rare and serious risks
The area is close to vessels that connect with the eye. In rare cases, the product can compress or enter a vessel, causing severe pain, changes in skin color and tissue loss. In very rare cases, there may be serious vision changes, including permanent loss. These are emergencies. I will tell the professional immediately if I notice any warning sign.
8. My health
I have truthfully reported my illnesses, allergies, medications, pregnancy or breastfeeding, eyelid surgeries and previous procedures in the area.
9. Alternatives
Other options were presented to me, including other treatments and the option not to treat. I freely choose this one.
10. Aftercare and follow-up
I received written instructions and know how to reach the professional: ________. Planned follow-up: ________.
11. No guarantee of results
I understand that the result cannot be guaranteed. Simulations and illustrative images are only for discussing possibilities.
12. 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.
13. 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: ________
Generic template, not legal advice. Have a lawyer review it and check your professional board's rules. Whoever signs is responsible for the content.
How do you align expectations about dark circles?
Show what each cause allows. A shadow from volume loss usually responds better to volume treatment; a brownish color does not. Common patient questions are covered in under-eye filler: results and sessions and risks of under-eye filler .
"Dark circles can have more than one cause. Filler helps with the shadow from the step, but it may not change the color. Let's look together at which one is yours before deciding."
Hand over the post-procedure instructions in writing and have the hyaluronidase in the office routine ready.
In Harmy, Tear Trough is a marking point. The projection is an illustrative simulation for discussing volume and does not promise results.
