Healthcare Biostimulators Consent Form

HEALTHCARE BIOSTIMULATORS CONSENT FORM

Patient Information

Date of Birth:

Insurance Information (if applicable)

Medical History & Current Medications

Please indicate if you have any of the following conditions (check all that apply):

Procedure Description

I authorize the administration of injectable biostimulator therapy (collagen biostimulant) to the following treatment area(s):

The physician or authorized clinician will perform injections using sterile technique. Biostimulators are intended to stimulate the patient's own collagen production over time. Multiple treatment sessions may be required to achieve the desired clinical outcome.

Risks, Potential Complications, and Expected Outcomes

I understand that, as with any injection procedure, risks include but are not limited to: pain, bruising, swelling, redness, tenderness, itching, infection, hematoma, nodule or granuloma formation, asymmetry, contour irregularity, delayed onset inflammatory reaction, scarring, texture changes, and the possible need for additional treatment or corrective procedures. In rare instances, vascular occlusion may occur, which can result in tissue necrosis, scarring, permanent injury, or vision impairment.

Biostimulator products produce gradual improvement as new collagen forms; immediate volumizing effect may be due to volumizing carrier and is not always reflective of final clinical result. Results are variable and not guaranteed. Maintenance treatments may be necessary to sustain results.

Alternatives

Alternatives include: no treatment, topical therapies, energy-based procedures, dermal fillers of other compositions, fat grafting, surgical alternatives, or other therapies recommended by the clinician. I have had the opportunity to discuss alternative options with my clinician.

Pre-Procedure and Post-Procedure Instructions

I agree to follow pre-procedure instructions including avoidance of blood-thinning medications and supplements where medically appropriate, and to notify the clinician of recent illness, infection, or new medications. Post-procedure care may include cold compresses, avoidance of strenuous activity for 24–48 hours, and avoidance of direct sun exposure as advised. Failure to follow instructions may increase the risk of complications.

Consent and Authorization

I certify that I have provided a full and accurate medical history and medication list. I have had the risks, benefits, expected outcomes, and alternatives explained to me in a manner I understand. I have had the opportunity to ask questions and have received satisfactory answers.

I consent to the performance of injectable biostimulator treatment by the clinician named below and authorize any additional services that the clinician deems necessary for my care in the event of unforeseen circumstances. I understand that no guarantee has been made to me regarding the outcome or efficacy of the procedure.

Photographs and Medical Records

I authorize the clinician and facility to take clinical photographs for documentation, treatment planning, and medical records. Photographs may be used for education or quality assurance in a de-identified manner. I authorize release of medical information necessary for treatment, billing, and follow-up care.

HIPAA / Privacy Authorization

By signing below I acknowledge receipt of the facility's privacy practices and authorize the release of protected health information for purposes of treatment, payment, and healthcare operations as required. I understand my rights regarding confidential information and who may receive my health information.

Financial Responsibility

I understand that cosmetic procedures may not be covered by insurance and I accept financial responsibility for services provided. I authorize the provider to bill my insurance when appropriate and understand I remain responsible for any charges not covered by insurance. I consent to release information to my insurer as necessary.

Withdrawal of Consent

I understand I may withdraw this consent at any time by providing written notice; however, withdrawal will not affect actions already taken in reliance on my consent prior to receipt of such notice.

Authorization Expiration

This authorization will remain in effect until the following expiration date or until revoked in writing, whichever occurs first.

Expiration Date:

Additional Patient Statements

I attest that I have been truthful about my medical history and that I understand the information on this form. I have had the opportunity to ask questions about the procedure, risks, benefits, and alternatives, and all my questions have been answered to my satisfaction.

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