Healthcare Patient FaceTite Consent Form

FACE TITE CONSENT FORM

Patient Information

Date of Birth:    Gender: Male Female Other

Insurance Information

Procedure Description

I authorize the physician and authorized staff to perform radiofrequency-assisted lipolysis and soft-tissue coagulation known as FaceTite on the following treatment areas:

Submental Jowls Neck Lower face Other:

Local anesthesia Local with sedation General anesthesia

Risks, Complications and Expected Outcomes

The physician has explained the nature and purpose of FaceTite, the intended benefits, and the material risks, which include but are not limited to:

• Thermal injury or burns to skin or deeper tissues
• Infection, seroma, hematoma or fluid accumulation
• Scarring, contour irregularity, asymmetry or persistent induration
• Nerve injury with numbness, weakness, or paresthesia (which may be temporary or permanent)
• Prolonged swelling, pain, or discoloration
• Need for additional procedures or revision
• Unsatisfactory aesthetic result; no guarantee of specific outcome

I have read and understand the risks and potential complications described above and discussed with the physician.

Alternatives

Reasonable alternatives to FaceTite were discussed and include: no treatment, observation, external non-invasive therapy, liposuction, or surgical lift procedures. I understand these alternatives and their relative risks and benefits.

I acknowledge that alternatives were discussed and I have had the opportunity to ask questions.

Medical History / Current Medications

I have a bleeding disorder or am taking blood thinners.    I am a current smoker.    I am pregnant or breastfeeding.

Photography and Use of Records

I consent to clinical photography and video for medical records, treatment planning, and quality assurance. I authorize the use of de-identified images for educational or scientific purposes. I understand identifiable images will not be used without separate written consent.

I consent to photography and use as described above.

HIPAA / Privacy Acknowledgment

I acknowledge receipt of the facility's privacy practices and understand my protected health information may be used for treatment, payment and health care operations as necessary. I authorize release of medical information to my insurer as required for billing.

I acknowledge the privacy practices as described and authorize release of information as needed.

Preoperative and Postoperative Instructions

Preoperative instructions, including medication adjustments and fasting, have been explained to me. I understand postoperative care, the need to follow all instructions, attend follow-up appointments, and contact the clinic for any concerns.

I have received and understand the preoperative and postoperative instructions.

Authorization and Release

By signing below I authorize the physician and staff to perform FaceTite and any ancillary procedures deemed necessary for my care. I understand that no guarantees have been made concerning the results. I accept financial responsibility for services not covered by insurance.

This authorization is valid until:

I certify that I have read and fully understand this consent form, that my questions have been answered, and that I freely give my informed consent to proceed.

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