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.

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

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 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

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

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

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, and that possible results of such complications are 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

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