Healthcare Cosmetic Document

Healthcare Cosmetic Consent and Medical History

Patient Information

Date of Birth:    Gender: Female Male Other

Insurance Information (if applicable)

Medical History

Diabetes    Hypertension    Heart disease    Bleeding disorder    Autoimmune disorder    None of the above

Are you pregnant or planning pregnancy within the next 6 months? Yes No

Do you smoke or use nicotine products? Yes No

Procedure Information and Consent

Scheduled Date:    Performing Clinician:

Local    Topical    Conscious sedation    General anesthesia

Risks, Benefits, and Alternatives

I acknowledge that the clinician has explained the nature of the proposed cosmetic procedure, expected benefits, reasonable alternatives (including no treatment), and the material risks and complications. Known risks include, but are not limited to: infection, bleeding, scarring, asymmetry, contour irregularity, skin discoloration, prolonged swelling or bruising, nerve injury, poor or delayed healing, allergic reaction to medications or materials, and the possible need for revision procedures. Serious but uncommon risks include deep tissue injury, vision changes, stroke, and death.

I understand that no guarantee or warranty has been made as to the results, and that additional procedures may be necessary to achieve desired results. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.

Consent Authorizations

By checking the boxes below and signing this document I authorize the clinic and its licensed staff to perform the described procedure, to administer anesthesia or sedation as indicated, and to provide any emergency treatment that may be necessary during or after the procedure.

I consent to the performance of the cosmetic procedure as described.
I consent to the administration of anesthesia or sedation as determined by the clinician or anesthesiologist.
I consent to clinical photography and video recording for documentation, treatment planning, and medical records. I understand that photographs may be used for education or publication unless I expressly deny permission below. I deny permission for non-medical use of my images.

I authorize release of medical information necessary for billing and insurance processing and accept financial responsibility for charges not covered by insurance.

HIPAA Authorization & Privacy Acknowledgment

I acknowledge receipt of the clinic's privacy practices and authorize the release of my protected health information for treatment, payment, and healthcare operations. I understand that I may request restrictions on certain disclosures, and that I may revoke this authorization in writing except to the extent that action has already been taken in reliance upon it.

I acknowledge receipt of the privacy practices and authorize release as stated above.

Authorization Period and Revocation

This authorization is valid for disclosures and uses related to the treatment and billing for the procedure and expires on: . I understand I may revoke this authorization at any time by submitting a written request, except where disclosures have already been made in reliance on this consent.

Patient Certification

I certify that the information I have provided on this form is complete and accurate to the best of my knowledge. I have read this consent in full, understand the nature of the procedure and the risks described, and consent to the procedure and related care as indicated above. I acknowledge that the clinician has discussed foreseeable risks and alternatives with me and that no guarantees have been made regarding the outcome.

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