Healthcare Cynosure Document

Healthcare Cynosure Document

Patient Name:    Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History

Are you currently pregnant or breastfeeding?    Yes    No

Procedure Description and Consent

Procedure to be performed:    Scheduled Date:

I consent to the performance of the Cynosure treatment and any associated pre- or post-procedure care as described by the provider. The provider has explained the intended benefits, the material risks (including but not limited to scarring, pigmentation changes, burns, infection, nerve injury, incomplete or unsatisfactory results), reasonable alternatives, and the expected recovery process.

I understand that no guarantee has been made as to the results and that additional treatments may be necessary. I accept financial responsibility for the cost of the procedure and for any subsequent treatment required for complications or revision that are not covered by insurance.

I acknowledge that I have had the opportunity to ask questions about the procedure and alternatives, and that those questions have been answered to my satisfaction. I understand I may withdraw this consent at any time prior to the administration of the treatment.

Photography and Use of Images

I authorize clinical photography for medical documentation. I understand photographs may be used for my medical record and, if expressly authorized below, for educational or promotional purposes without identifying information.

I authorize medical documentation photographs.    I authorize use for educational/promotional purposes

HIPAA Authorization and Release of Medical Records

I hereby authorize the release and disclosure of my protected health information related to the treatment described above to the parties designated below for the purpose of treatment, payment and health care operations. This authorization includes images, procedure notes, operative reports, and clinic notes.

Expiration of Authorization:    If no date is provided, this authorization expires one year from the date of signature.

I understand I may revoke this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance on this authorization. I understand that information disclosed pursuant to this authorization may be redisclosed by the recipient and may no longer be protected by privacy regulations.

I acknowledge receipt of the facility's Notice of Privacy Practices and have been given the opportunity to discuss how my protected health information will be used and disclosed.
I acknowledge receipt of the Notice of Privacy Practices.

Patient Certification

By signing below I certify that the information provided is true and complete to the best of my knowledge, that I have read and understand this consent and authorization, and that I consent to the procedure and related releases described herein. I accept responsibility for following all pre- and post-procedure instructions provided by the treating clinician.

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