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Compliance · Template

General Aesthetic Treatment — Sample Consent Template

A general informed-consent structure for aesthetic treatment — a starting point to take to your attorney and medical director, not a finished form.

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. Complete every [bracketed] field, and have your attorney and medical director verify the risk list is complete and accurate, adapt the language to your state and the specific procedure, and approve it before any use.

Patient & practice information

Practice / clinic name:
Patient name:
Date of birth:
Date of treatment:
Treating provider:
Supervising / medical director (if applicable):

The treatment

I am requesting and consent to the following treatment: [describe the specific procedure(s) and product(s)]. The nature of the treatment, what it involves, and what to expect during and after have been explained to me by my provider.

Risks and possible complications I understand and accept

  • Common, generally temporary effects such as redness, swelling, bruising, tenderness, or discomfort at the treatment site
  • Asymmetry, uneven or unsatisfactory results, or the need for additional treatment
  • Infection, allergic or hypersensitivity reaction
  • Less common but more serious complications specific to this treatment, which my provider has discussed with me: [your clinicians must list the complete, accurate, procedure-specific risks here]
  • Other risks explained to me verbally and in response to my questions

Alternatives

I understand there are alternatives, including other treatments and choosing no treatment at all, and these have been discussed with me.

Results are not guaranteed

I understand that aesthetic results vary from person to person, that no specific result has been or can be guaranteed, and that additional treatments or maintenance may be needed.

Acknowledgments

  • I have read (or had read to me) and understand this document.
  • I have had the opportunity to ask questions, and my questions have been answered to my satisfaction.
  • I have disclosed my relevant medical history, medications, allergies, and conditions, and they are accurate.
  • I am consenting voluntarily and may decline or stop treatment at any time.

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.
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