Healthcare Brow Removal Consent Form

Healthcare Brow Removal Consent Form

Patient Information

Patient Name:

Male Female Other

Insurance Information

Procedure Description

I authorize the provider to perform brow removal procedures as selected below. These may include laser hair removal, electrolysis, chemical depilatory application, or surgical excision. The provider has explained the planned technique and site of treatment.

Laser hair removal
Electrolysis
Chemical depilatory
Surgical excision
Other:

Risks, Benefits and Alternatives

The benefits of brow removal may include the reduction or elimination of eyebrow hair and improvement in cosmetic appearance. The provider has explained expected outcomes but cannot guarantee specific cosmetic results.

Known risks include, but are not limited to: skin irritation, redness, blistering, scarring, infection, pigmentary changes (hypopigmentation or hyperpigmentation), asymmetry, persistent numbness or altered sensation, allergic reaction to topical agents, thermal injury, and the potential need for additional procedures to achieve desired results. There is risk of recurrence of hair growth and incomplete removal. Surgical excision may result in a visible scar.

Alternatives include no treatment, trimming, temporary depilatory methods, or referral to an alternative treatment modality. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.

I acknowledge that I understand the risks, benefits, and alternatives described above, and consent to proceed with the selected procedure(s).

Medical History

Do you have any of the following? (check all that apply)

Bleeding disorder
History of keloid or hypertrophic scarring
Cardiac pacemaker or implanted electronic device
Immunosuppression or autoimmune disease
Diabetes mellitus

Are you pregnant or trying to become pregnant? Yes No

Pre-Procedure Instructions and Acknowledgment

I understand and agree to the following pre-procedure instructions as applicable: avoid aspirin and nonsteroidal anti-inflammatory drugs for 7 days prior unless prescribed by my physician; avoid tanning or sunburn in the treatment area for at least 2 weeks; disclose all topical or oral medications; arrive with the treatment area clean and free of makeup; follow any additional provider instructions.

I confirm that I have read and will follow the pre-procedure instructions or have discussed modifications with the provider.

Photography and Use of Records

Photographs may be taken for clinical documentation, treatment planning, and clinical education. Identifying information will be handled as protected health information under applicable privacy laws.

I consent to clinical photography for my care.
I decline photography

HIPAA / Privacy Acknowledgment

I acknowledge that the provider has provided a notice of privacy practices describing how my medical information may be used and disclosed. I understand that my protected health information will be used for treatment, payment, and healthcare operations and that I may request restrictions on certain uses.

I acknowledge receipt of privacy information and consent to use my health information for treatment purposes.

Authorization Term

This authorization for treatment will remain in effect until the date indicated below unless I revoke it earlier in writing. I understand that revocation will not affect actions taken in reliance on this authorization prior to revocation.

Expiration Date:

Consent and Certification

By signing below I certify that I am the patient or authorized representative. I certify that I have read and understand this consent form, that the nature and purpose of the procedure(s) have been explained to me, that potential risks and complications have been described, and that the provider has answered my questions to my satisfaction. I understand that no guarantee has been made concerning the results. I authorize the provider and staff to perform the procedure(s) as described above.

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