Fill and Sign the Release Form

Waiver and Release Form for Cosmetic Surgery Cosmetic Surgery Questionnaire (Please initial each page at the bottom). 1. Name of Patient ___________________________________________________ 2. Address of Patient _________________________________________________ 3. Medical Insurance Carrier ___________________________________________  Policy or Group Number _____________________________________ 4. What type of cosmetic surgery are you considering? ______________________ ________________________________________________________________  Have you ever had any cosmetic procedures before? [ ] YES [ ] NO  If yes, please describe the procedure? ____________________________ ______________________________________________________________  Where was the procedure performed? ____________________________  Name of Physician who performed procedure ________________________ 5. Do you have any history of depression or mental illness? [ ] YES [ ] NO 6. Do you have any medical allergies? [ ] YES [ ] NO  If Yes, please describe, particularly the type of reaction you have. ________ ________________________________________________________________ ________________________________________________________________ 7. Are you on any medications or hormones? [ ] YES [ ] NO  If yes, please list the names of the medication or hormone. ______________ ________________________________________________________________ ________________________________________________________________ 8. Do you take any over the counter medications on a regular basis like aspirin or , antihistamines, etc.)? [ ] YES [ ] NO 9. Do you have any of the following medical problems?  Heart disease [ ] YES [ ] NO  Lung disease [ ] YES [ ] NO  High blood pressure [ ] YES [ ] NO  Asthma [ ] YES [ ] NO  Diabetes [ ] YES [ ] NO  Liver disease [ ] YES [ ] NO  Bleeding problems [ ] YES [ ] NO  Kidney disease [ ] YES [ ] NO  Pulmonary embolus [ ] YES [ ] NO  Thrombo phlebitis (vein inflammation) [ ] YES [ ] NO  Hepatitis [ ] YES [ ] NO  Immune suppression [ ] YES [ ] NO  Artificial joints or heart valves [ ] YES [ ] NO  Other medical problems _________________________________________ ________________________________________________________________ 10. Name of your primary care physician___________________________________ 11. With any surgery procedure it is very important to relay history of an abnormal bleeding problem. Any abnormal bleeding tendencies can cause complications both during and after surgery.  Do you have abnormal or heavy periods? [ ] YES [ ] NO If yes, please describe ______________________________________________ ___________________________________________________________________  Do you have recurrent nose bleeds? [ ] YES [ ] NO If yes, please describe ______________________________________________  Have you had persistent bleeding after tooth extractions? [ ] YES [ ] NO If yes, please describe ______________________________________________  Do you have a history of anemia (low blood count)? [ ] YES [ ] NO If yes, please describe ______________________________________________  Do you have a history of easy bruising? [ ] YES [ ] NO If yes, please describe ______________________________________________  Do you have any family members with abnormal bleeding? [ ] YES [ ] NO If yes, please describe ______________________________________________  Do you have fever blisters? [ ] YES [ ] NO Your insurance carrier will not cover the service rendered today because this service is not covered under your insurance plan. Agreement The undersigned acknowledges and agrees that he/she has read the above statement and understands that his/her insurance company will not pay for the medical services that will be performed for cosmetic reasons. Therefore, the undersigned does hereby accept full financial responsibility for these services, and acknowledges that payment for these services is due on the date of the procedure on the undersigned. ___________________________ ______________________________ (Printed Name of Witness) (Printed Name of Patient) ___________________________ ______________________________ (Signature of Witness) (Signature of Patient) Parent or Guardian must sign if Patient is under 18 years of age. I, as parent or guardian of the above named Patient agree individually and on behalf of my child or ward, to the terms of the above Agreement. WITNESS my signature on this the ____ day of ___________, 20____. __________________________ __________________________________ (Printed Name of Witness) (Printed Name of Parent or Guardian) __________________________ __________________________________ (Signature of Witness) (Signature of Parent or Guardian) Authorization to Take and Publish Photographs, Images, and Audio Visual Materials I hereby authorize ________________ (Name of Physician) , my physician or someone selected or authorized by ________________________ (Name of Clinic of Physician) to obtain photographs, images, and/or audio/visual materials of me related to my cosmetic treatment. I hereby authorized and release any photographs, images, or audio/visual materials taken in the course of my cosmetic treatment to _______________________ (Name of Clinic of Physician) for use in: medically related publications; in-office patient; education materials; and/or marketing materials. Such uses may be for one or more of the following purposes:  Medical education — (medically-related publications, brochures, slides, letters to be used within the medical community);  Non-medical education — (slides for lectures to civic groups, social organizations, service organizations, etc), patient education (i.e., photographs used to show prospective surgery candidates comparisons pre- and post- surgery), and/or  Marketing [to show comparisons before and after surgery to prospective patients utilizing print (such as newspapers, newsletters, magazines, brochures, handouts, office literature) and/or electronic media such as __________________________ (Name of Clinic) ’s internet website]. I understand that photographs, images, or audio/visual materials of which I am subject shall become the property of ________________________ (Name of Clinic) . All such photographs, images, or audio/visual materials shall become a part of my medical record and shall be retained in accordance with state regulations. This authorization and release shall remain in effect until I revoke it in writing. I grant this authorization and release because I favor the advancement of medical science, public education, and/or the promotion of services of ___________________ _______________ (Name of Clinic) . I have read this authorization and release, understand its content, and have full capacity to execute it. WITNESS my signature on this the ____ day of _____________, 20____. ___________________________ ______________________________ (Printed Name of Witness) (Printed Name of Patient) ___________________________ ______________________________ (Signature of Witness) (Signature of Patient) Parent or Guardian must sign if Patient is under 18 years of age. I, as parent or guardian of the above named Participant agree individually and on behalf of my child or ward, to the terms of the above Authorization . WITNESS my signature on this the ____ day of ___________, 20____. __________________________ __________________________________ (Printed Name of Witness) (Printed Name of Parent or Guardian) __________________________ __________________________________ (Signature of Witness) (Signature of Parent or Guardian) Consent, Waiver and Release In consideration of the cosmetic surgery to be performed and any further surgery that may, in the opinion of the medical staff of __________________________ (Name of Clinic) be necessary, the undersigned, hereinafter referred to as Releasor, fully realizing that such surgery may be unsuccessful, that it may have certain complications, including, but not limited to, (list complications) ______________________________ _____________________________________________________________________ , and that possible results of such complications are (list) ________________________ ________________________, requests that such cosmetic surgery be performed, and consents to the cosmetic surgery. Releasor releases and forever discharges ______________________ (Name of Physician) , ___________________________ (Name of Clinic) , its directors, medical and surgical staff, agents, employees and any other persons connected with such cosmetic surgery, from all claims, damages and causes of action that may arise from the surgery described in this release, and from other medical care arising from the same, including post-surgical treatment. Releasor agrees that no representations have been made regarding the success of this cosmetic surgery to Releasor, except as set forth in this Consent, Waiver and Release. This Consent, Waiver and Release shall be binding on ____________________ (Name of Patient) , and on the heirs, legal representatives and assigns of Releasor. Releasor has read all the terms of this instrument and understands that he/she is signing a complete release and bar to any claim resulting from the Cosmetic Surgery described in this Consent, Waiver and Release. Releasor has executed this release this the _____ day of ______________, 20_____. ___________________________ ______________________________ (Printed Name of Witness) (Printed Name of Patient) ___________________________ ______________________________ (Signature of Witness) (Signature of Patient) Parent or Guardian must sign if Patient is under 18 years of age. I, as parent or guardian of the above named Patient agree individually and on behalf of my child or ward, to the terms of the above Consent, Waiver and Release. WITNESS my signature on this the ____ day of ___________, 20____. __________________________ __________________________________ (Printed Name of Witness) (Printed Name of Parent or Guardian) __________________________ __________________________________ (Signature of Witness) (Signature of Parent or Guardian)