Healthcare Med Spa Consent Form

HEALTHCARE MED SPA CONSENT FORM

Med Spa Name:    Location/Clinic:

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance / Billing (if applicable)

Policy Number:    Group Number:

Medical History

Current Medications (including topical agents):

Allergies (medication, latex, adhesives, foods, topical products):

Do you have any of the following conditions? (check all that apply)

Diabetes    Heart disease    Hypertension    Autoimmune disorder    Bleeding disorder

History of keloid scarring    Active herpes/simplex outbreaks    Current or recent isotretinoin use (last 6 months)

Are you pregnant or breastfeeding?    Yes    No

Procedure Information and Consent

Provider / Injector:    Estimated number of treatments/sessions:

Type of anesthesia/topical analgesia to be used:    Topical    Local injection    None / Not applicable

Risks, Benefits, and Alternatives

I understand the intended benefits of the proposed procedure include cosmetic improvement in the treated region. I acknowledge that no guarantee of specific results has been made. I understand the reasonably foreseeable risks may include, but are not limited to:

• Infection, delayed healing, scarring, or keloid formation;
• Temporary or permanent changes in skin pigmentation (hyperpigmentation or hypopigmentation);
• Bruising, swelling, pain, or numbness in treated areas;
• Allergic reaction to products, topical agents, anesthetic or dressings;
• Asymmetry, contour irregularity, need for additional or corrective treatment;
• Unanticipated complications or unsatisfactory cosmetic outcome.

I acknowledge that alternatives to the proposed treatment, including no treatment, medical therapy, or alternative cosmetic procedures, have been explained and discussed as appropriate.

By checking the box below I acknowledge that risks, benefits, and alternatives were explained and I have had an opportunity to ask questions and receive satisfactory answers.

I acknowledge that I understand the risks, benefits, and alternatives described above.

Contraindications and Pre-Treatment Representations

I represent that I do not have an active infection, open wound, or inflammatory skin condition at the proposed treatment site. I confirm that I have disclosed all medications, past and current medical conditions, and cosmetic procedures. I understand certain conditions (including recent isotretinoin use, active cold sores, or recent laser/chemical treatments) may contraindicate treatment.

Patient attests (check all that apply):

No active infection at treatment site    Not currently on isotretinoin    No procedure on area within last 30 days

Photography and Use of Images

Clinical and procedural photography may be taken for medical records, treatment planning, and assessment of results. Photographs may also be used for educational or marketing purposes only with separate explicit consent. Patient authorizes use of de-identified images for the following purposes (check applicable):

Medical records and treatment planning    Education and professional presentations    Marketing and promotional materials (optional)

HIPAA Authorization and Privacy Acknowledgment

I acknowledge receipt of the facility's Notice of Privacy Practices and authorize the use and disclosure of my protected health information for treatment, payment, and healthcare operations as reasonably necessary. I understand I may request restrictions and may revoke this authorization in writing to the extent permitted by law; however, revocation will not affect information already released or actions taken in reliance on this authorization.

Authorization expiration date (if any):    If left blank, authorization expires when treatment relationship ends.

Post-Treatment Instructions and Acknowledgment

I understand that specific pre- and post-treatment care instructions have been provided verbally and/or in writing. I agree to follow these instructions and to notify the clinic promptly if I experience unexpected symptoms, severe pain, signs of infection, or other concerns.

I acknowledge receipt of pre/post-treatment instructions and agree to follow them.

Release, Indemnification and Consent

By signing below, I request and consent to the performance of the procedures described above by qualified personnel. I authorize the practitioner and staff to perform such procedures and to administer such anesthetic agents or medications as deemed necessary. I release and hold harmless the facility, its practitioners, employees and agents from liability for outcomes and complications that are not the result of gross negligence or willful misconduct. I agree to indemnify the facility for claims arising from my failure to provide accurate medical history or to follow instructions.

I understand that no assurances or guarantees have been made to me regarding the results of the procedure. I have had the opportunity to ask questions regarding the nature and purpose of the procedure, risks and alternatives, and all of my questions have been answered to my satisfaction.

I certify that the information I have provided on this form is complete and accurate to the best of my knowledge.

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