Cosmetic Procedure Informed Consent

Effective Date: Date✕

Organization: Organization Name✕

Participant / Signer: Full Name✕

I authorize Provider Name✕ of Clinic Name✕ to perform the following cosmetic procedure on me: Procedure✕. The provider has explained the procedure, expected results, alternatives, and the risks listed below.

Risks and Side Effects

I understand that the procedure carries risks including, but not limited to: bruising, swelling, redness, asymmetry, allergic reaction, infection, scarring, nerve injury, and unsatisfactory cosmetic result. Individual results vary and cannot be guaranteed.

Alternatives

The provider has discussed alternative treatments and the option of receiving no treatment.

Photographs

I consent to before/after photographs being taken for my medical record. I Agree / Do Not Agree✕ to the use of de-identified images for educational or marketing purposes.

Financial Responsibility

I understand that fees are payable at the time of service and are non-refundable once the procedure has begun.

Acknowledgment

I have read this consent, had the opportunity to ask questions, and voluntarily authorize the procedure.