Healthcare Cosmetic Clinic Agreement

Healthcare Cosmetic Clinic Agreement

Clinic Name:    Clinic Address:

Patient Name:    Agreement Date:

Patient Information

Male    Female    Other    Prefer not to disclose

Emergency Contact

Insurance Information

Medical History

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

Diabetes    Hypertension    Heart disease    Bleeding disorder    Autoimmune disorder

Are you pregnant, attempting to become pregnant, or breastfeeding?   Yes    No

Procedure Details

Risks, Benefits, and Alternatives

I understand that the proposed cosmetic procedure is elective. Risks include but are not limited to infection, bleeding, scarring, asymmetry, nerve injury, allergic reaction, unsatisfactory aesthetic outcome, need for revision procedures, and unpredictable healing. The practitioner has explained the expected benefits and that results cannot be guaranteed.

Alternatives to the proposed treatment have been explained, which may include no treatment, medical therapy, or different procedural options. I have had an opportunity to ask questions and understand the material risks and alternatives.

I acknowledge that risks, benefits, and alternatives were explained to me and that I have been given an opportunity to ask questions.

Pre-Procedure & Post-Procedure Instructions

I agree to follow the clinic's pre-procedure and post-procedure instructions, including medication adjustments, avoidance of blood-thinning agents as directed, and follow-up appointments. Failure to follow instructions may increase the risk of complications and may affect eligibility for treatment.

I acknowledge receipt of pre- and post-procedure instructions and agree to comply.

Photography and Use of Images

I consent to clinical photography for treatment documentation and clinical education. I understand that identifiable images will not be used externally for marketing or promotional purposes without my separate written authorization unless I select permission below.

I consent to use of photographs for clinical documentation and education.
I consent to use of photographs for marketing and promotional purposes (optional).

Financial Terms, Cancellation, and Refunds

I agree to be responsible for all fees associated with the procedure. Deposits are required to reserve appointments. Deposits are non-refundable except as required by applicable law unless the clinic cancels the appointment. Cancellations made within seventy‑two (72) hours of a scheduled procedure may be subject to forfeiture of the deposit and additional cancellation fees. Final payment is due at the time of service unless other arrangements are made in writing.

If insurance is billed, I understand that cosmetic elective procedures are frequently not covered; I remain responsible for any balance not paid by insurance.

HIPAA / Privacy Acknowledgment

I acknowledge receipt of the clinic's Notice of Privacy Practices. I understand how my protected health information may be used and disclosed for treatment, payment, and healthcare operations as described in that notice. I authorize the clinic to use and disclose my protected health information as necessary to provide care and process payments.

I acknowledge receipt of the clinic's Notice of Privacy Practices and authorize use and disclosure as described.

Emergency Treatment Authorization

In the event of an emergency related to the procedure, I authorize the clinic and its staff to secure and administer emergency medical treatment and to arrange for transportation to an appropriate medical facility if required. I agree to be financially responsible for any emergency care or transportation.

I authorize emergency treatment and transportation as described above.

Release, Indemnity, and Acknowledgments

By signing below I release the clinic, providers, and their staff from liability for ordinary negligence to the extent permitted by law, and I agree to indemnify and hold harmless the clinic for claims arising from my failure to disclose relevant medical information or to follow pre- or post-procedure instructions. Nothing in this agreement waives claims for gross negligence or willful misconduct where prohibited by law.

I understand and agree to the release and indemnity provisions set forth above.

Voluntary Consent and Right to Withdraw

I certify that I have read and fully understand this agreement, that my questions have been answered, and that I freely consent to the proposed cosmetic procedure. I understand I may withdraw this consent at any time prior to the procedure by providing written notice to the clinic; withdrawal may affect scheduling and financial obligations as described above.

I voluntarily consent to the procedure described above and acknowledge my right to withdraw prior to treatment.

Additional Notes / Special Instructions

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