General

By signing these forms, you acknowledge that they are in good standing for 1 year and will be updated annually; it is your responsibility to inform us of any changes to your medical history.

Name

First NameLast Name

Nickname

Birth Date

Date

Gender

Marital Status

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Preferred Method of Communication

Emergency Contact

First NameLast Name

Relationship to you

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

I allow release of my medical information to this person.

How did you hear about us?

Referral or Other

Please list all allergies to medication, foods, and materials.

Please list all medications/supplements you are currently taking with dosages.

Please list all surgical history.

Please select any medical conditions that apply to you.

Please describe medical condition/s if necessary.

Alcohol Use

Smoking Status

Any recreational drug use?

How often do you exercise?

Purpose of Consent

This form provides you with information about how Fab Fusion Aesthetics collects, uses, and protects your personal health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA). This consent is necessary to proceed with the administration of neurotoxin/dermal filler injections and IV infusions.

Privacy Practices

By signing this consent form, you acknowledge that you have been informed of Fab Fusion Aesthetics's Privacy Practices Notice. This notice outlines how your protected health information (PHI) may be used and disclosed and your rights regarding your PHI. You can review the Privacy Practices Notice in detail at any time by requesting a copy from our office.

Uses and Disclosures of Your Health Information

Your PHI may be used and disclosed for purposes related to your treatment, payment for services, and healthcare operations. This includes, but is not limited to:

-Treatment: We may use your PHI to provide, coordinate, or manage your care, including consultations with other healthcare professionals.

-Payment: We may use and disclose your PHI to obtain payment for services provided, such as billing insurance companies or other payers, or other billing and collection activities and utilization review.

-Healthcare Operations: We may use your PHI to improve our services, conduct quality assessments, and comply with legal and regulatory requirements.

Your Rights

You have the following rights regarding your PHI:

-Right to Access: You can request access to your medical records and receive copies.

-Right to Amend: You can request an amendment to your health records if you believe there is an error or omission.

-Right to Restrict: You can request restrictions on the use and disclosure of your PHI.

-Right to Confidential Communications: You can request that we communicate with you in a certain way or at a certain location.

Acknowledgment and Consent

I, the undersigned, have read and understand the Privacy Practices Notice provided by Fab Fusion Aesthetics. I consent to the use and disclosure of my protected health information as outlined above for the purpose of receiving neurotoxin/dermal filler injections and IV infusions.

I understand that I may withdraw my consent at any time by providing written notice to Fab Fusion Aesthetics, but this will not affect any actions taken before the withdrawal.

Please list the names of any individuals you authorize to receive information regarding your medical treatments and records. If none, skip this question.

Signature

Date

Purpose of Consent

This form allows Fab Fusion Aesthetics to use photographs, videos, and/or audio recordings taken during or after the administration of neurotoxin/dermal filler injections and IV infusions for marketing, educational, and promotional purposes.

Consent to Use Images, Videos, and or Audio Recordings

By consenting to photographs, video, and/or audio recordings I understand I will not be compensated from any party. Although the photographs, video, and/or audio recordings will be used without identifying information such as a name, I understand it is possible someone may recognize me.

I further acknowledge that my participation is voluntary and agree that use of any photographs, video, and/or audio recordings confers no rights of ownership or royalties whatsoever.

(Please initial one)

Initial

I DO give permission for my photographs, video, and/or audio recordings to be used in advertisements created for the sole use of Fab Fusion Aesthetics’ website and/or social media accounts to show before and after results. Fab Fusion Aesthetics may also use the photographs, video, and/or audio recordings taken for educational or training purposes.

Initial

I DO give Fab Fusion Aesthetics permission to use the photographs, video, and/or audio recordings taken for in-office educational and training purposes only.

Initial

I DO NOT give permission to use the photographs, video, and/or audio recordings taken for any purposes outside of documentation in my own medical record.

Rights and Waivers

I understand that I will not receive any financial compensation for the use of these images and videos. I further understand that I have no right to inspect or approve the finished materials before they are published or distributed.

I hereby waive any right to inspect or approve the use of the photographs, videos, and/or audio recordings and any related written copy that may be used in conjunction with them. I release Fab Fusion Aesthetics and its representatives from any claims, demands, or liabilities arising out of or in connection with the use of the images, videos, and/or audio recordings.

Confidentiality

Fab Fusion Aesthetics will make reasonable efforts to ensure that the use of these materials respects patient confidentiality and privacy. However, the nature of public and promotional content means that absolute confidentiality cannot be guaranteed.

Consent and Agreement

I have read and understood the contents of this Video and Photo Consent and Release Form. I consent to the use of my images, videos, and/or audio recordings as described above.

Signature

Date

Form

General Intake

Social History

HIPAA Consent Form

Video and Photo Consent Release Form