Procedure Consent Form

First Name *

Last Name *

Date of birth *

Email *

Choose one or more services *

I, the undersigned, authorize Z Med Clinic Provider/Injector and/or their associates to perform the medical procedure(s) named above.

I agree.

General Consent

• The expected benefits, potential risks, complications, and possible side effects of the procedure(s) have been explained to me.

• No guarantees or promises regarding outcomes have been made.

• I have had the opportunity to ask questions and all questions were answered to my satisfaction.

• I understand the nature of the procedure, associated risks, and available alternatives, including not undergoing treatment.

• I understand I may refuse or withdraw consent at any time before the procedure without affecting future care.

• I have been informed of alternative treatment methods with associated risks and benefits.

• I understand that local or topical anesthesia may be used and consent to its administration if deemed necessary.

Laser / Energy-Based Procedure Specific Risks:

• Redness, swelling, and discomfort that may last several hours to several days- weeks.

• Blistering, crusting, scabbing, or burns, including superficial or deeper skin injury.

• Changes in skin pigmentation, including post-inflammatory hyperpigmentation (PIH) or hypopigmentation, temporary or permanent.

• Infection, scarring, or delayed healing.

• Reactivation of herpes simplex virus (cold sores) in susceptible individuals.

• Unsatisfactory results or the need for additional treatments.

Laser Risk Acknowledgment

I specifically acknowledge that I have read, understand, and accept the risks associated with laser and energy-based procedures as

outlined above.

I agree.

Pre- and Post-Treatment Care Compliance for all services above (not limited to laser):

I agree to follow all pre-treatment and post-treatment instructions provided to me by Z Med Clinic for the services listed above, including but not limited to laser-based procedures. I understand that failure to follow these instructions may increase the risk of complications, delay healing, and negatively affect treatment outcomes and results.

Authorization for Use of Photographs, Video Recordings, and Testimonials:

I hereby give my consent to [ZMED Clinic Providers PA, and Z MEDI SPA, LLC] associates to photograph, film, videotape and then use, for charting and office professional business use.I also agree that those pictures or and Videos to be used for marketing purposes and may be reproduced and publish said images or vidoes of me and/or my child/children.I agree that photographs/negatives, film, or videotapes thereof shall constitute the sole property of [ZMED Clinic Providers, and Z MEDI SPA, LLC]], with full right of disposition in any manner whatsoever, including the right to publish these pictures online.I hereby release [ZMED Clinic Providers, and Z MEDI SPA, LLC]and his/her legal representatives and assigns from any and all claims whatsoever in connection with the use, reproduction, publication of the images thereof.

Agree

Disagree

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