Healthcare Silicone Form

Healthcare Silicone Form

Patient Information

Insurance Information

Medical History

Are you currently pregnant or breastfeeding? Yes No

Do you have a bleeding disorder or take blood thinners? Yes No

Procedure Details

Type of silicone product/prosthesis (select all that apply): Silicone implant Silicone injection/filler Other

Risks, Benefits and Alternatives

I acknowledge that my clinician has explained the nature and purpose of the proposed silicone procedure, the potential benefits, reasonable alternatives (including no treatment), and the material risks. Potential significant risks include, but are not limited to: infection; scarring; chronic pain; device migration; rupture or leakage of implant or filler; granuloma or foreign body reaction; need for additional or revision surgery; impairment of diagnostic testing; sensory changes or numbness; allergic reaction; and unpredictable cosmetic outcome. There may be unknown long-term effects associated with silicone-based procedures.

Alternatives to the proposed procedure, including non-surgical management and alternative implant or filler materials, have been discussed. I understand that results cannot be guaranteed and that additional treatment or corrective procedures may be necessary.

Please acknowledge the following by checking each box:

I have received and understand an explanation of the risks and benefits.

I have been informed of reasonable alternatives, including no treatment.

I have had the opportunity to ask questions and have received satisfactory answers.

Informed Consent and Authorization

By signing below I authorize the clinician and clinical staff to perform the silicone procedure described above and to provide such ancillary services as are necessary for my care, including administration of local anesthesia, sedation, wound care, and any additional interventions that may become necessary in the course of treatment. I authorize the use of silicone materials as discussed and accept responsibility for their known and potential risks.

I understand that if an unexpected condition arises during the procedure, the treating clinician may take such actions as are deemed appropriate for my health and safety. I accept financial responsibility for the procedure and for care required as a result of complications unless otherwise covered by insurance.

I understand that I may revoke this authorization at any time by providing written notice; however, revocation will not affect actions already taken in reliance on this authorization prior to receipt of the revocation.

HIPAA Authorization and Privacy Acknowledgment

I acknowledge that I have received information regarding the practice's privacy practices and that I consent to the use and disclosure of my protected health information for treatment, payment, and healthcare operations in accordance with applicable privacy regulations. I authorize release of my medical information to my insurance carrier and to other healthcare providers for coordination of care.

Authorization to photograph: I authorize clinical photography or video recording for the purpose of treatment documentation, medical education, and quality assurance. I understand that such images will be retained in my medical record and used without patient identification unless additional authorization is obtained for public use.

Aftercare and Acknowledgment

I understand post-procedure instructions will be provided and that compliance with aftercare is essential to reduce risk of complications. I agree to follow all instructions and to contact the clinic promptly in the event of unexpected symptoms such as fever, increasing pain, excessive swelling, discharge, or other signs of infection or adverse reaction.

I certify that the information I have provided on this form is accurate and complete to the best of my knowledge. I have read and fully understand this consent and authorization. I acknowledge that no guarantees have been made to me regarding the outcome of the procedure.

Sign Now