Spa Patient Paperwork 2024

Notice of Privacy Practices Acknowledgement
St. Louis Cosmetic Surgery Medical Spa

17300 North Outer Forty Road, Suite 300

Saint Louis, MO 63005

Phone: 636-425-2866

Fax: 636-777-7500

I understand that, under the Health Insurance Portability & Accountability Act of 1966 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
Obtain payment from third-party payers.
Conduct normal healthcare operations such as quality assessments and physician certifications.

I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the above address to obtain a current comp of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.
Name*

First NameLast Name
Signature*

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Confidential Communications
Patient's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
For Oral communications, please call the number below: *
Please enter a valid phone number.
If you are unavailable at this number, may we leave a message on an answering machine or voicemail message?*

YesNo
Do we have permission to disclose your health information to another person other than yourself?*

YesNo
Please List Name and Relationship
Signature*

Clear
Date*

MonthDayYear
Date

Informed Consent for Care
Any questions you have regarding the nature and purpose of your treatment(s) and/or procedure(s) will be discussed and explained to your satisfaction. My signature acknowledges that I have read the following: I, (first name/last name), consent to and authorize the staff of St. Louis Cosmetic Surgery Medical Spa to perform treatments as discussed between myself and my practitioners.
Signature*

Clear
I understand that with any treatment, certain risks are involved and that any complications or side effects from known or unknown causes could occur. I freely assume these risks.*
I have stated all medical conditions of which I am aware and will inform my practitioner of any changes in my health status or routine*
I agree to adhere to all safety precautions and home skin care programs as recommended by my practitioner.*
I will contact the Medical Spa to inform my practitioner of any complications or concerns I may have as soon as they occur. If no one is available, I will leave a message with my contact information detailing my issues. *
Signature*

Clear
Date*

MonthDayYear
Date

Photographic Consent Agreement and Release
St. Louis Cosmetic Surgery Medical Spa desires to photograph treated areas of each patient before and after rendering aesthetic services to document improvement in the appearance of treated areas.

Note:
- Skin care patients may have a Visia image made of their full face to evaluate skin condition, determine proper care, and to document improvement.
- Some specific treatments require full-face photographs
- St. Louis Cosmetic Surgery Medical Spa agrees NOT to use the patient’s name together with their full-face photograph(s) without separate, express written consent.
Before and After photos are required for most Medical Spa treatments. Patient agrees to allow St. Louis Cosmetic Surgery Medical Spa to take photographs of the treatment area for your PRIVATE medical file. *
In addition to the above, please check yes or no next to each usage described below that you agree(yes) or disagree (no) to allow us permission to use your photographs:
Educational Presentations*

YesNo
Portfolio of results to be shown to patients*

YesNo
Social Media*

YesNo

COVID-19 Consent Form
I, the undersigned patient, consent to an in-person consultation and/or to have my Doctor and/or his/her staff (hereinafter collectively “my Doctor”) perform medical procedures, whether regarded as necessary, elective or aesthetic, during the time of the COVID-19 pandemic and after. I understand in-person consultations and/or having my procedure performed at this time, despite my own efforts and those of my Doctor, may increase the risk of my exposure to COVID-19. I am aware that exposure to COVID-19 can result in severe illness, intensive therapies, extended intubation and/or ventilator support, life-altering changes to my health, and even death. I am also aware of the possibility that the procedure itself, whether performed in my Doctor’s office or in a hospital, may result in a more severe case of COVID-19 than I might have had without the procedure.*
I also understand in-person consultations and/or having my procedure performed at this time increases the risk of my transmission of COVID-19 to my Doctor. This virus has a long incubation period, there may be as yet unknown aspects of its transmission, and I realize that I may be contagious, whether or not I have been tested or have symptoms. To reduce the possibility of COVID-19 exposure or transmission at my Doctor’s office, I accept that my Doctor will implement infection-control procedures with which I must comply, before, during and after my consultation and/or procedure, for my own protection as well as that of my Doctor. I understand my cooperation is mandatory, whether or not I personally feel such COVID-19 procedures and/or preventive measures are necessary.*
I have informed my Doctor of any COVID-19 testing I or any person living with me during the past 14 days has received, as well as the results of that testing, and if I am tested between now and the date of my procedure, I will immediately provide the results of that testing to my Doctor. I understand my Doctor may require that I be tested, possibly at my own expense and regardless of any prior testing, and that the results of that testing must be satisfactory to my Doctor, before I may receive my procedure. I understand I must honestly disclose this information to avoid putting myself and others at risk.*
All topics above have been discussed with me, and all my questions have been answered to my satisfaction. Being fully informed, I accept the risk of COVID-19 exposure and I will bear the cost of any COVID-19 treatments required. I have been given the opportunity to postpone my in-person consultation and/or procedure until the COVID-19 pandemic is less prevalent, but I choose to have my in-person consultation and/or procedure performed now. If I am the parent, guardian or conservator of the patient, I hold his/her health care power of attorney. I have read this COVID-19 Informed Consent Agreement and am authorized to consent on the patient's behalf. *
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

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Should be Empty:

Spa Patient Paperwork

Employment Information

Emergency Contact Information

Spa Treatments to Discuss:

Spa Profile and Assessment

Notice of Privacy Practices Acknowledgement

Confidential Communications

Informed Consent for Care

Photographic Consent Agreement and Release

COVID-19 Consent Form