Healthcare Cosmetic Package

HEALTHCARE COSMETIC PACKAGE

Patient Information

Patient Name:    Date of Birth:

Insurance Information (if applicable)

Selected Cosmetic Package

Please indicate desired treatments included in the cosmetic package. Specific services, quantities and fees are set forth below.

Medical History & Current Health

Do you have any of the following chronic conditions? Check all that apply:

Procedure Description, Risks and Benefits

The practitioner will perform the cosmetic services checked above as part of the selected package. I acknowledge that the procedures are elective and that no specific outcome can be guaranteed. Specific benefits may include improvement in appearance, texture, or symmetry of treated areas. I understand inherent and potential risks, which include but are not limited to: infection, bleeding, scarring, asymmetry, pigmentary changes, prolonged swelling or bruising, allergic reaction to products or anesthetic agents, nerve injury, need for revision procedures, and unsatisfactory aesthetic result.

I understand that additional or alternative treatments may be necessary to achieve or maintain results and that results may deteriorate over time. I have had the opportunity to ask questions concerning the nature of the procedures, potential risks and complications, alternative treatment options and expected postoperative course.

Consent, Authorization and Acknowledgements

By signing below I: (a) authorize the practitioner and clinical staff to perform the cosmetic services selected above; (b) consent to administration of topical, local, or other indicated anesthesia; (c) authorize necessary ancillary procedures, including photographs, to document treatment and medical recordkeeping; and (d) confirm that I have provided complete and accurate medical history to the best of my knowledge.

I understand I may withdraw consent at any time prior to the initiation of treatment and that withdrawal of consent will not affect the care provided for complications that arise from the procedures already performed.

I acknowledge that no guarantees have been made regarding results: Initials:    I understand the refund/cancellation terms: Initials:

Payment, Cancellation and Refund Policy

A deposit is required to reserve appointment times and secure package pricing. Deposits are applied to the package price. The balance is due in full on or before the day of final treatment as set by the clinic. Cancellations made less than 72 hours prior to a scheduled appointment may forfeit the deposit. Refunds for elective cosmetic services are limited: retreatments or partial refunds are provided at the clinic's discretion when clinically warranted.

Photography & Use of Images

I authorize clinical photography for the purpose of medical records and treatment planning. I further consent to the use of anonymized images for educational purposes. I understand that use of identifiable images for marketing purposes requires additional, separate written authorization.

Privacy & HIPAA Acknowledgment

I acknowledge that the clinic has provided a notice describing the uses and disclosures of my protected health information under applicable privacy laws. I understand that the clinic may use and disclose protected health information for treatment, payment and healthcare operations in accordance with law.

Authorization Expiration

This authorization for treatment and use of medical information shall remain in effect until:

Representations and Certification

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I have had the opportunity to ask questions and understand the treatment plan, associated risks, alternatives, and post-treatment instructions. I accept financial responsibility for the services rendered according to the terms above.

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