Healthcare Facial Agreement

HEALTHCARE FACIAL AGREEMENT

Client Name:   Date of Birth:

Provider & Visit Details

Provider Name:   Date of Visit:

Patient Information

Insurance & Payment

Insurance Provider:   Policy/ID #:

Medical & Skin History

Current medications (prescription and over-the-counter):

Known allergies (medication, latex, topical products):

Prior surgeries or procedures on the face (including cosmetic lasers/peels):

Have you used isotretinoin (Accutane) or systemic retinoids within the last 12 months?   Yes    No

Procedure Description & Options

Optional procedural add-ons (check all that apply):

Risks, Benefits & Alternatives

The benefits of the procedure include improvement in skin texture, tone, and hydration. Known and reasonably foreseeable risks include temporary redness, swelling, bruising, pigmentary changes (hyperpigmentation or hypopigmentation), scarring, infection, allergic reaction to topical agents, delayed healing, and unsatisfactory cosmetic outcome. Minor adverse events are common; serious adverse events are uncommon but possible.

Alternatives include medical skincare management, less invasive procedures, or deferring treatment. There is no guarantee of a specific outcome, and multiple treatments may be required for optimal results.

Pre- and Post-Treatment Instructions & Cancellations

I agree to follow pre-treatment instructions provided by the practitioner, including avoidance of tanning, depilatory procedures, and certain topical agents for the specified periods prior to treatment. I understand failure to follow instructions may increase the risk of complications or necessitate treatment rescheduling.

Cancellation policy: I understand fees may apply for no-shows or late cancellations as established by the provider. I am financially responsible for services rendered and for any costs not paid by insurance.

HIPAA & Photography Authorization

I acknowledge receipt of the provider's privacy practices governing use and disclosure of my protected health information. I consent to the use of my health information for treatment, payment, and healthcare operations as described by applicable privacy law.

Photography: Clinical photographs may be taken for the medical record and treatment planning. Photographs used for teaching, marketing, or social media will be de-identified unless I give separate authorization below.

Authorization & Expiration

By signing below I authorize the provider and staff to perform the facial treatment and authorized add-ons selected above, to administer topical agents, and to provide such additional care as deemed necessary in the exercise of professional judgment in the course of treatment.

This authorization is effective on the date signed and will expire on:

Voluntary Consent

I certify that I am of sound mind, that I have read this agreement (or it has been read to me), that the treatment, risks, benefits, and alternatives have been explained, and that all of my questions have been answered to my satisfaction. I understand I may withdraw consent at any time prior to or during the procedure.

Additional Authorizations / Notes

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