General Consent For Treatment, Procedures, Photography, Video Recording, And Provider To Client Treatment.
You have been given information about your condition and the recommended procedure(s) to be used. This consent form is designed to provide an electronic and written confirmation of such discussions by recording some of the more significant medical information given to you. It is intended to make you better informed so that you may give or withhold your consent to the proposed procedure(s). Heather Merlo, APRN, FNP-C has explained to me that the condition(s) in my case discussed during our initial consultation, and any consultation thereafter would benefit from treatments offered at Sei Tu Bella Aesthetics and offered a treatment modality and ‘or intervention. I have been provided ample time to ask any questions regarding the procedure and thereafter. Risks/Benefits of Proposed Procedure(s):
Just as there may be benefits to the procedure(s) proposed, I also understand that interventions and medical procedures involve risks. These risks include the following but not limited to allergic reaction, bleeding, blood clots, infections, paralysis, vascular compromise and or occlusion, burns, discolorations, granulomas, adverse side effects of drugs, blindness, and in the rare and unfortunate event of even loss of bodily function or life.
I understand that the medical clinic is recorded for safety and security purposes and can be used for any means to protect all providers and Sei Tu Bella Aesthetics LLC
I understand that I have been instructed to activate my treatment portal and there I can find my client paperwork, consents, and pre and post-instructions as well via the website. I understand that at any time I am unsure of the treatment process, pre and post-treatment instructions, risks, benefits, or any other concern I have been provided a means to reach the clinic for additional guidance.
I understand that if I do not disclose all of my medical history and physical which includes previous and current treatment interventions, including any changes after I sign this consent, it can lead to an adverse effect or event. I also realize that there are particular risks associated with the procedure(s) proposed for me and that these risks include, but are not limited to, those enumerated in the addendum.
Complications; Unforeseen Conditions; Results: I am aware that in the practice of medicine, other unexpected risks or complications not discussed may occur. I also understand that during the course of the proposed procedure(s) unforeseen conditions may be revealed requiring the performance of additional procedures, and I authorize such procedures to be performed. I further acknowledge that no guarantees or promises have been made to me concerning the results of any procedure or treatment.
Acknowledgments: The available alternatives, the potential benefits and risks of the proposed procedure(s), and the likely result without such treatment, have been explained to me. I understand what has been discussed with me as well as the contents of this consent form, and have been given the opportunity to ask questions and have received satisfactory answers. I have been made aware of all
consents and pre and post-treatment instructions to optimize the procedure are made available to me via the website and the portal.
Consent to Procedure(s) and Treatment: Having read this form and talked with the provider, my signature below acknowledges that: I voluntarily give my authorization and consent to the performance of the procedures agreed upon and The following consent is general consent for treatment as a client at Sei Tu Bella Aesthetics and includes verbal consent to any and all procedures, treatments, interventions, performed while remaining a client at Sei Tu Bella Aesthetics.
I take full liability and responsibility for any and all risks, undesired outcomes, or adverse events associated with the procedure and will not hold the providers or Sei Tu Bella Aesthetics LLC for any unfavorable outcome or adverse event. I release Sei Tu Bella Aesthetics LLC, owners, and medical staff from liability associated with the procedure. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns. I relieve Heather Merlo, APRN, FNP-C, Medical Director Dr. Fernando Jara , Sei Tu Bella Aesthetics LLC, from all legal action pertaining to this treatment.