Healthcare Aesthetics Agreement

HEALTHCARE AESTHETICS AGREEMENT

Patient Information

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Insurance Provider:    Policy/ID #:

Group #:    Subscriber Name:

Patient acknowledges that elective aesthetic procedures are frequently not covered by insurance and that the patient is responsible for payment unless otherwise agreed in writing.

Procedure & Treatment Plan

Proposed Treatment Date:    Treating Practitioner:

Medical History & Allergies

Have you experienced excessive bleeding, tendency to bruise, or a bleeding disorder? Yes

Are you pregnant, attempting to become pregnant, or breastfeeding? Yes

Do you have a history of autoimmune disease, keloid formation, or chronic skin conditions (e.g., psoriasis, eczema)? Yes

Risks, Benefits & Alternatives

The patient acknowledges that the practitioner has explained the nature of the proposed aesthetic procedure, expected benefits, likely results, and material risks including but not limited to infection, scarring, pigmentation changes, asymmetry, nerve injury, allergic reaction, prolonged swelling, or need for revision. Alternative treatment options (including no treatment) have also been discussed.

The patient understands that individual responses vary and that no guarantee has been made regarding outcome or duration of results.

Consent & Authorization

By signing this Agreement, patient authorizes the practitioner and authorized clinical staff to perform the aesthetic procedure described above and to administer such local anesthetic, topical agents, or ancillary care as deemed necessary. The patient understands and consents to the administration of standard ancillary procedures and immediate post-treatment management.

Patient grants permission for pre- and post-procedure clinical photography for treatment planning, assessment, and medical records. Photographs may be used for clinical education or publication only if explicit written authorization is provided separately. Consent for photography: I consent

The patient understands the right to withdraw consent prior to the start of a procedure. Withdrawal of consent does not absolve the patient of financial obligations for services already rendered or for a reasonable cancellation fee if applicable.

Payment, Cancellation & Refunds

Total Estimated Fee: $    Deposit: $

Appointment cancellation policy, late arrival and no-show fees have been explained. Refunds for cosmetic procedures are limited and governed by the clinic's policy; patient accepts responsibility for costs incurred.

Privacy & Medical Records

The practice maintains confidentiality of medical records except as required by law. Patient acknowledges receipt of the clinic's Notice of Privacy Practices and authorizes release of protected health information to other healthcare providers or entities as necessary for continuity of care.

I acknowledge receipt of the Privacy Notice: Acknowledged

Representations, Release & Indemnity

The patient represents that all information provided is truthful and complete to the best of the patient's knowledge. The patient releases the practitioner, clinic, and staff from liability for ordinary negligence except in cases of willful misconduct. The patient agrees to indemnify and hold harmless the practitioner and clinic from third-party claims arising from the patient's false statements or failure to follow pre- or post-procedure instructions.

Post-Procedure Care

The patient agrees to follow all post-procedure instructions provided in writing and to contact the clinic promptly for any complications. Failure to adhere to aftercare instructions may adversely affect outcomes and is the responsibility of the patient.

Authorization Term

This authorization to perform procedures and to release and use medical information for treatment and recordkeeping purposes expires on:

Acknowledgment & Certification

I certify that I have read and fully understand the terms of this Healthcare Aesthetics Agreement. I have had the opportunity to ask questions, all of which have been answered to my satisfaction. I consent voluntarily to the proposed treatment and accept the risks described herein.

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