Healthcare Patient Facial Consent Form

PATIENT FACIAL CONSENT FORM

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History

I am currently pregnant or breastfeeding:    History of bleeding disorder or taking blood thinners:    Have a pacemaker or implanted device:

Description of Procedure

Procedure to be performed:

Risks, Benefits and Alternatives

The provider has explained the nature and purpose of the proposed facial treatment and any expected benefits. I understand the procedure may include, but is not limited to: removal of surface tissue, controlled wounding, thermal injury, or abrasion to the skin. I acknowledge that no guarantee has been made regarding the result.

Potential risks and complications include, without limitation: infection, scarring, prolonged redness, pigmentation changes (hypo- or hyperpigmentation), textural irregularities, allergic reaction to topical agents, delayed healing, need for additional treatment, uneven results, and, rarely, permanent disfigurement. Risks related to anesthesia include allergic reaction and localized irritation. Additional unanticipated complications may occur.

Alternatives to the proposed procedure, including no treatment, medical therapy, or other procedures, have been discussed with me. I have had the opportunity to ask questions and to have them answered to my satisfaction.

Consent Items

I authorize the provider and clinical staff to perform the facial procedure described above and any additional procedures that are necessary or advisable during the course of the treatment.

I consent to the use of topical or local anesthetic agents as deemed appropriate by the provider.

I consent to clinical photography for medical records and assessment. I understand photographs are part of my medical record.

I consent to use of de-identified photographs for educational or marketing purposes. (If not checked, no marketing use will be made.)

HIPAA and Use of Protected Health Information

I acknowledge receipt of the practice's Privacy Practices. I authorize the use and disclosure of my protected health information for treatment, payment, and healthcare operations related to this procedure. This authorization includes disclosure to other healthcare providers, insurers, laboratories, and administrative personnel as necessary to carry out care and billing.

This authorization expires on:    I understand I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it.

Financial Responsibility and Acknowledgments

I understand that I am financially responsible for charges not covered by insurance. I consent to treatment and accept financial responsibility as described in the practice's financial policy. I authorize release of insurance information necessary for processing claims.

I certify that the information I have provided on this form is correct and complete to the best of my knowledge. I have had the opportunity to ask questions and all my questions have been answered in a satisfactory manner. I understand that no result is guaranteed and that additional procedures may be necessary to achieve the desired result.

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