Healthcare Plastic Surgery Agreement

HEALTHCARE PLASTIC SURGERY AGREEMENT

Parties and Patient Information

Provider (Surgeon / Clinic) Name:

Clinic Name:

Patient Name:

Date of Birth:    Gender:

Phone:    Email:

Procedure and Clinical Consent

Proposed Procedure Date:

I hereby authorize the Provider and such assistants as may be selected to perform the procedure(s) described above. I acknowledge that the Provider has explained the nature and purpose of the procedure, the intended benefits, the probable duration of the procedure, and the reasonably foreseeable risks and complications, which include but are not limited to infection, bleeding, scarring, asymmetry, nerve injury, sensory changes, need for revisional surgery, anesthesia risks, and unsatisfactory cosmetic result. I understand that results cannot be guaranteed.

Risks, Alternatives, and Acknowledgements

Alternatives to the proposed procedure, including non-surgical options and observation, have been discussed. I understand that additional or alternative procedures may be necessary if unforeseen conditions are discovered during surgery, and I authorize the Provider to perform such procedures when, in the Provider's professional judgment, they are necessary for my health or safety.

I acknowledge that no warranty or guarantee has been made regarding the results of the procedure. I accept the risks described above and consent to the administration of anesthesia (local, sedation, or general as indicated), including associated risks such as adverse drug reaction, respiratory complications, cardiac events, and, rarely, death.

Local anesthesia    Sedation    General anesthesia

Medical History

Do you smoke or use nicotine products? Yes No    Are you pregnant or planning pregnancy? Yes No

Photographs, Recordings, and Use of Images

I consent to clinical photography, video, and other imaging prior to, during, and after the procedure for the purposes of medical records, treatment planning, and clinical comparison. I understand identifying information will be handled in accordance with privacy laws.

I authorize use of de-identified images for teaching and publication: Yes No

I authorize use of images for marketing (e.g., brochures, non-identifying online use): Yes No

Insurance, Fees and Financial Responsibility

Estimated professional and facility fees have been discussed. Estimated total fee:    Required deposit:

I understand that I am financially responsible for all charges not covered by insurance, including deductibles, co-payments, co-insurance, and any non-covered services. I authorize release of medical information necessary to process claims and assign benefits to the Provider where applicable.

Patient acknowledges financial responsibility as stated above.

Cancellation, Post-Operative Care, and Follow-Up

Cancellation and rescheduling policies, including forfeiture of deposit for late cancellation, have been explained. I agree to follow post-operative instructions and to attend scheduled follow-up visits. Failure to follow instructions may adversely affect healing and results.

Complications and Emergency Treatment

In the event of an emergency or complication, I authorize the Provider to take such measures as are medically necessary, including hospitalization, anesthesia, or transfusion, and I consent to emergency treatment. The Provider will make reasonable efforts to contact my emergency contact.

Patient authorizes emergency treatment as described above.

Privacy and HIPAA Acknowledgement

I acknowledge that I have received or have been offered a copy of the Provider's Notice of Privacy Practices describing how my health information may be used and disclosed and my rights under privacy laws. I understand that photographs and medical records will be maintained in accordance with applicable privacy requirements.

Patient acknowledges receipt of privacy notice.

Authorization, Release and Expiration

By signing below I authorize the Provider and staff to perform the procedure(s) above and associated care. I release the Provider, clinic, and related personnel from liability for complications which are the known risks of the procedure, except in cases of gross negligence or willful misconduct. I agree to indemnify and hold harmless the Provider for any claims arising from my own failure to disclose pertinent medical information or failure to follow pre- or post-operative instructions.

This authorization expires on:

I understand that I may withdraw this consent in writing at any time prior to the procedure, except to the extent that action has already been taken in reliance upon it.

Patient acknowledges right to withdraw consent in writing prior to procedure.

Certifications and Signatures

I certify that the information I have provided is accurate and complete to the best of my knowledge. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction. I understand the nature of the procedure, the risks, possible complications, and alternatives.

Sign Now