Healthcare Hair Removal Agreement

HEALTHCARE HAIR REMOVAL AGREEMENT

Provider Name:     Clinic Address:

PATIENT INFORMATION

INSURANCE & BILLING

MEDICAL HISTORY

Have you used isotretinoin (Accutane) within the last 6 months?   Yes No

PROCEDURE DETAILS

Treatment Area(s):

Proposed Modality / Device:

RISKS, BENEFITS & ALTERNATIVES

I understand the nature and purpose of hair removal treatment, and I have had the procedure, risks, benefits, and reasonable alternatives explained to me. Potential risks include, but are not limited to: temporary or permanent pigmentary changes, scarring, blistering, burns, infection, paradoxical hair growth, pain, and incomplete hair removal. I acknowledge no guarantee of permanent hair removal is made.

Initial to confirm you understand the risks and benefits:

PRE-TREATMENT & POST-TREATMENT INSTRUCTIONS

I acknowledge receiving the following instructions and will comply unless otherwise instructed by the provider:

• Avoid sun exposure and tanning for four weeks prior to treatment and for four weeks after treatment.
• Avoid waxing, plucking, or bleaching treated areas for recommended intervals.
• Disclose all medications and supplements prior to treatment, including photosensitizing agents.
• Avoid topical irritants on treatment day; keep treated skin clean and protected.

I confirm I have read and will follow pre- and post-treatment instructions: Yes No

PHOTOGRAPHY & RECORDS

Photographs may be taken for medical records, treatment planning, and clinical comparison. Identifying photographs will be treated as protected health information. I consent to clinical photography for the purposes described. Consent Do Not Consent

HIPAA / PRIVACY ACKNOWLEDGMENT

I acknowledge that I have received or been offered the provider's Notice of Privacy Practices describing how my protected health information may be used and disclosed, and my rights with respect to that information. I authorize the use and disclosure of my medical information for treatment, payment, and healthcare operations as described in that Notice.

Acknowledged: Yes

FINANCIAL RESPONSIBILITY & CANCELLATION

I accept financial responsibility for all charges for services provided by the clinic that are not paid by insurance or are not covered. I understand cancellation policy and fees may apply for missed or late appointments, and that prepayment or deposit may be required for certain procedures.

Patient initials to acknowledge financial responsibility:

AUTHORIZATION, RELEASE & CONSENT

By signing this Agreement, I authorize the provider and authorized staff to perform hair removal treatment as described. I certify that I have provided accurate medical history and have had an opportunity to ask questions. I release the provider and clinic from liability for known and unknown risks of the treatment, except for gross negligence or willful misconduct. This release includes claims for personal injury, scarring, pigmentation change, or other complications related to treatment.

I understand that I may withdraw this authorization at any time by providing written notice to the provider, except where action has already been taken in reliance upon this authorization.

Authorization Expiration Date:

ADDITIONAL CONSENTS

I consent to administration of topical or local anesthetics as needed, understanding that all anesthetics carry risk of allergic reaction and other complications.

Consent to anesthetic: Yes No

ACKNOWLEDGMENTS

I acknowledge that no warranties or guarantees have been made to me regarding the outcome of the treatment. I certify that I am not pregnant or breastfeeding unless I have disclosed this to the provider and have received clearance.

Pregnancy / Breastfeeding: Yes No

SIGNATURE

Sign Now