Healthcare Medical Spa Consent Form

HEALTHCARE MEDICAL SPA CONSENT FORM

Clinic Name:    Provider/Practitioner:

Patient Information

Date of Birth:    Gender (check one): Female Male Other/Prefer not to say

Insurance Information (If Applicable)

Medical History

Are you pregnant, planning pregnancy, or breastfeeding? Yes No

Procedure / Treatment Information

Treatment Area:    Proposed Treatment Date:

Risks, Benefits, and Alternatives

I understand that the proposed procedure and ancillary treatments may involve risks including, but not limited to: bruising, swelling, pain, infection, scarring, hypo- or hyperpigmentation, temporary or permanent nerve injury, allergic reaction to topical or injected agents, and unsatisfactory aesthetic result. Rare but serious complications may occur and may require additional medical treatment.

Benefits and realistic outcomes have been explained to me. Alternatives, including no treatment and other treatment options, have been discussed. I acknowledge that no guarantees or promises have been made regarding results.

Contraindications, Pre- and Post-Treatment Instructions

I confirm I have informed the practitioner of all medications, supplements, and medical conditions. I have been instructed to avoid sun exposure, tanning, and certain medications or supplements (including but not limited to isotretinoin, blood thinners, and high-dose vitamin E) for a specified period prior to treatment. I agree to follow pre- and post-care instructions provided by the clinic.

I acknowledge that failure to follow instructions may increase the risk of complications. I agree to notify the clinic promptly if unexpected symptoms or adverse events occur after treatment.

Authorization, Photography, and Release

I authorize the practitioner and clinic staff to perform the procedure described above. I authorize the use of topical or local anesthetics and other medications as deemed necessary. I consent to immediate, necessary emergency treatment should an adverse event occur.

I authorize clinical photography for medical documentation and treatment planning. Photographs may be used for internal education, quality assurance, or anonymized clinical presentations unless I indicate otherwise below.

HIPAA / Privacy Acknowledgment

I acknowledge receipt of and/or opportunity to review the clinic's Notice of Privacy Practices describing how my protected health information may be used and disclosed. I authorize the release of treatment or billing information to the following person(s) as needed:

Financial Policy and Fees

I understand that certain aesthetic procedures may not be covered by insurance and I am financially responsible for charges not covered. Cancellation policies, deposit requirements, and no-show fees have been explained to me. I authorize release of necessary information for billing and collections.

Consent and Certification

By signing below I certify that I have read and fully understand this consent form, that all of my questions have been answered to my satisfaction, and that no guarantee has been made as to the results of the procedure. I understand I may withdraw my consent at any time prior to the procedure. I acknowledge that this document will become part of my permanent medical record.

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