Dermal Filler Treatment — Sample Consent Template
A sample informed-consent structure for dermal filler treatment — a starting point for your attorney and medical director to complete and approve.
SAMPLE TEMPLATE ONLY — your attorney must review before any use. This is a SAMPLE starting point provided for general educational purposes only. It is NOT legal or medical advice, is NOT guaranteed to be complete, accurate, or compliant for your state or your specific procedure, and is NOT ready to use as-is. You MUST have your own attorney and medical director review, complete, and adapt it before any use. Bracketed [fields] must be filled in, and the risks listed must be verified by your clinicians as complete and accurate for the specific treatment. It is provided "as is," without warranty of any kind, and the publisher accepts no responsibility or liability for its use.
An original Money Racket template
A sample structure only, for dermal filler treatment. Complete every [bracketed] field, and have your medical director verify the risks (including vascular complications) are complete and accurate and your attorney adapt and approve it for your state before any use.
Patient & practice information
Practice / clinic name:
Patient name:
Date of birth:
Date of treatment:
Treating provider:
Product & areas treated:
The treatment
I consent to dermal filler treatment (product: [____]) to the following area(s): [____], to add volume and/or contour. My provider has explained the treatment and what to expect.
Risks and possible complications I understand and accept
- Temporary effects such as redness, swelling, bruising, tenderness, or lumps/firmness
- Asymmetry, over- or under-correction, or unsatisfactory results, and the possible need for adjustment or dissolving (for HA fillers)
- Infection, allergic or hypersensitivity reaction, or nodule formation
- Rare but serious vascular complications (including vascular occlusion), which my provider has discussed with me, along with how they are managed
- Other risks specific to this product and area that my provider has discussed: [clinicians must list the complete, accurate, current risks here]
Important acknowledgments
- I understand serious vascular complications are rare but possible, and that prompt management may be required.
- I have disclosed any pregnancy, breastfeeding, prior filler, autoimmune conditions, medications, and relevant history.
- I will follow the aftercare instructions and report concerning symptoms promptly.
Results are not guaranteed
I understand results vary and are not permanent, that no specific outcome is guaranteed, and that additional product or touch-ups may be discussed.
Acknowledgments
- I have read (or had read to me) and understand this document.
- My questions have been answered to my satisfaction.
- My disclosed medical history, medications, and allergies are accurate.
- I am consenting voluntarily.
Signatures
Patient (or legal representative) — signature & date
Provider — signature & date
SAMPLE TEMPLATE ONLY — your attorney must review before any use. This is a SAMPLE starting point provided for general educational purposes only. It is NOT legal or medical advice, is NOT guaranteed to be complete, accurate, or compliant for your state or your specific procedure, and is NOT ready to use as-is. You MUST have your own attorney and medical director review, complete, and adapt it before any use. Bracketed [fields] must be filled in, and the risks listed must be verified by your clinicians as complete and accurate for the specific treatment. It is provided "as is," without warranty of any kind, and the publisher accepts no responsibility or liability for its use. © 2026 Money Racket.