Patient Consent Form

PATIENT CONSENT AND SERVICE AGREEMENT

WHEREAS, Provider Name: is duly authorized and qualified to provide the medical and ancillary services described herein; and

WHEREAS, Patient Name: seeks to receive such services and has the capacity to provide informed consent; and

WHEREAS, the parties desire to set forth the scope of treatment, payment terms, confidentiality obligations and other terms governing the relationship between Provider and Patient.

Patient Information

Scope of Work / Services

Provider will perform the following services and related care. Patient acknowledges that the scope below describes the primary services but may include ancillary or follow-up services reasonably related to treatment:

Consent and Acknowledgements

By checking each box and signing below, Patient expressly authorizes Provider to perform the services described above and acknowledges the following specific consents and understandings:

I consent to the administration of treatment, examinations, and tests as reasonably necessary for the services described.

I consent to anesthesia or sedation if required, and understand associated risks.

I consent to clinical photography or video recording for treatment, record-keeping, or training purposes as described by Provider.

I authorize release of medical records to third parties for treatment, payment, or healthcare operations, where reasonably necessary.

I acknowledge that Provider has explained the material risks, benefits, and reasonable alternatives to the proposed treatment and that no guarantees or assurances of results have been made. Initials:

Payment Terms

Patient agrees to pay Provider for services rendered in accordance with the following terms:

Late payment will incur a late fee of: . Patient is responsible for all fees not covered by insurance. I accept financial responsibility.

Term and Termination

This Agreement commences on Start Date: and continues until End Date: unless earlier terminated in accordance with this section.

Either party may terminate this Agreement for convenience upon providing written notice at least days prior to termination. Provider may terminate immediately for material nonpayment or conduct that jeopardizes care.

Confidentiality

Provider shall maintain the confidentiality of Patient's medical and personal information in accordance with applicable law and professional standards. Provider may disclose information when required by law, court order, or to protect the welfare of the patient or public.

Patient authorizes Provider to use and disclose protected health information to the extent necessary for treatment, payment, and healthcare operations. Patient may revoke such authorizations in writing except to the extent that action has already been taken.

Governing Law; Entire Agreement

This Agreement shall be governed by the laws of the State of without regard to its conflict of laws principles.

This Agreement, together with any attached informed consent documents and scheduling or billing addenda signed by the parties, constitutes the entire agreement between Patient and Provider and supersedes all prior agreements and understandings, whether written or oral, relating to the subject matter herein. Any amendment must be in writing and signed by both parties.

Acknowledgement of Understanding

By signing below, Patient acknowledges that they have read this Agreement, had an opportunity to ask questions, and voluntarily consent to the terms, treatments, and payment obligations described. Patient also affirms they are not under the influence of any substance that impairs decision-making.

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