Healthcare MedSpa Agreement

HEALTHCARE MEDSPA AGREEMENT

This MedSpa Agreement (Agreement) documents the informed consent, disclosures, payment terms, and authorizations for aesthetic and medical spa treatments to be provided by the Clinic. Client and Provider acknowledge and agree to the terms set forth below.

PARTIES AND IDENTIFICATION

Date of Birth:    Gender:

Phone:    Email:

EMERGENCY CONTACT

Relationship:    Phone:

INSURANCE & BILLING

Insurance Carrier:

Policy / ID #:    Group #:

Subscriber Name (if different):

I understand that most elective aesthetic procedures are not covered by insurance and I am financially responsible for fees assessed by the Clinic unless otherwise agreed in writing.

PROPOSED TREATMENT

Estimated number of sessions:

MEDICAL HISTORY / SCREENING

Do you use blood thinners, aspirin, or anticoagulants?    Are you pregnant or attempting to become pregnant?

Have you had an adverse reaction to local anesthetic or injectable agents?

ANESTHESIA, SEDATION & MEDICATIONS

The Clinic will discuss anesthesia options when applicable. I understand that any sedation carries additional risks, that I must disclose all medications and substances, and that post-procedure monitoring may be required. I consent to the administration of topical, local, or minimal sedation as deemed appropriate by the treating clinician.

Consent for anesthesia: Topical    Local injectable    Minimal sedation

RISKS, BENEFITS, AND ALTERNATIVES

The patient acknowledges receipt of a clear description of the recommended treatment, expected benefits, material risks, and reasonable alternatives. Material risks of aesthetic procedures may include, but are not limited to: infection, bleeding, bruising, swelling, pain, scarring, changes in pigmentation, asymmetry, allergic reaction, delayed healing, nerve injury, and unsatisfactory aesthetic result. Rare but serious complications (including tissue necrosis and systemic complications) have been disclosed when relevant.

The treating clinician has the right to modify or discontinue treatment if, in their professional judgment, continuation would be unsafe. The patient may withdraw consent at any time prior to treatment commencement.

PHOTOGRAPHY / MEDIA RELEASE

Photographs and diagnostic images may be taken before, during, and after treatment for medical documentation. I consent to clinical photography for treatment planning and internal medical records.

I authorize the Clinic to use de-identified photographs for education, quality assurance, and scientific purposes:    I authorize the Clinic to use identifiable photographs for marketing only with my separate written consent:

PAYMENT, CANCELLATION, AND NO-SHOW POLICY

Total Fee / Estimate: $    Deposit required: $

Deposits are applied toward services and are non-refundable except where required by law. Cancellation with less than 48 hours notice may result in forfeiture of deposit or imposition of a cancellation fee. No-shows may be charged in full for the scheduled service.

Payment method on file: Credit Card    Cash    Other

POST-PROCEDURE CARE & FOLLOW-UP

The patient agrees to follow post-procedure instructions provided by the Clinic. Failure to follow aftercare instructions may increase risk of complications and may affect the outcome. If complications arise, the patient will contact the Clinic promptly and attend any recommended follow-up visits.

HIPAA / PRIVACY ACKNOWLEDGMENT

I acknowledge receipt of the Clinic's Notice of Privacy Practices and understand how my protected health information may be used and disclosed for treatment, payment, and healthcare operations. I authorize the Clinic to use and disclose my health information as described in that notice.

AUTHORIZATION & CONSENT

By signing below, I authorize the treating clinician and Clinic staff to perform the procedures described above, and to administer such medications and therapies as are necessary in their professional judgment. I certify that the information I have provided is accurate and complete to the best of my knowledge and that I have fully disclosed my medical history, medications, allergies, and pregnancy status if applicable.

I understand that no guarantee has been made to me regarding the results of any procedure. I release and hold harmless the Clinic and its employees from liability for any adverse effects resulting from treatments, except for willful misconduct or gross negligence.

REPRESENTATIONS & PATIENT ATTESTATION

I represent that I am of legal age and competent to consent, or that I am the legal guardian or authorized representative of the patient and have authority to execute this consent. I have had the opportunity to ask questions and have received satisfactory answers regarding risks, benefits, alternatives, and expected outcomes.

I consent to the release of necessary medical information for billing and treatment coordination. I authorize the Clinic to obtain additional medical records relevant to my care from other providers when necessary.

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