Patient Treatment Prep Sheet

PATIENT TREATMENT PREP SHEET

Patient Name:    Date of Birth:    Patient ID:

WHEREAS / RECITALS

WHEREAS Patient Name: is scheduled to receive the treatment described below;

WHEREAS Provider Name: will perform or supervise the treatment in accordance with applicable professional standards;

WHEREAS both parties acknowledge that adherence to pre-treatment instructions materially affects safety and clinical outcome.

Treatment Details / Scope of Treatment

Appointment Details

Treatment Type:    Provider:

Appointment Date:    Time:    Location/Room:

Pre-Treatment Checklist (patient must acknowledge)

I will fast as instructed prior to treatment (if required by procedure).

I will abstain from alcohol for 24–72 hours prior to treatment as directed.

I will follow instructions concerning temporary cessation of medications (blood thinners, NSAIDs, supplements). If applicable, stop days prior:

I will avoid intentional sun exposure and tanning for the period recommended prior to treatment.

I will arrive with the treatment area clean and free of cosmetics, lotions, or perfumes.

Medical History & Allergies

Do you have any known allergies to medications, topical agents, or latex? Yes No

Current prescription medications (including anticoagulants and hormone therapies):

Relevant medical conditions (check all that apply):

Heart disease or history of cardiac events

Diabetes

Bleeding disorder or clotting abnormality

Pregnant or breastfeeding

Immunosuppressed or on immunomodulating therapy

Payment Terms

Agreed treatment fee: $    Deposit required at scheduling: $

Late fee or collection: will apply to overdue balances.

Term, Cancellation & Termination

Treatment start date:    Expected completion date:

Cancellation and rescheduling requires at least days' notice. Provider reserves the right to terminate scheduled services for material noncompliance with pre-treatment instructions or nonpayment; any refunds will be subject to the provider's cancellation policy as set forth above.

Confidentiality

All medical records, treatment notes, and personal information disclosed in connection with treatment are confidential and will be maintained in accordance with applicable privacy laws. Provider may disclose information to necessary treatment personnel or as required by law. Patient authorizes limited sharing of preparatory information for scheduling, pre-op clearance, insurance processing, or emergency care.

Acknowledgment and Certifications

By signing below, I certify that the information I have provided on this Patient Treatment Prep Sheet is complete and accurate to the best of my knowledge. I acknowledge that I have received, read, and understand the preparatory instructions provided above and will follow them prior to my appointment. I understand that failure to follow these instructions may increase the risk of complications or may result in postponement or cancellation of treatment.

I consent to the performance of the proposed treatment as described and accept financial responsibility as set forth in the Payment Terms. I understand that results cannot be guaranteed and that all procedures carry inherent risks. I have had the opportunity to ask questions and have received satisfactory answers.

Governing Law & Entire Agreement

This Patient Treatment Prep Sheet and any related agreements shall be governed by the laws of the state in which the provider's practice is located, without regard to conflict-of-law principles. This document, together with any written consent or treatment plan executed contemporaneously, constitutes the entire agreement between the parties regarding pre-treatment instructions and related administrative terms and supersedes prior oral or written representations.

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