• Belleza Esthetic Center

    Miami Surgical Location “In collaboration with Provocative Plastic Surgery”Clinic Location: 860 NW 42nd Avenue,Suite 300 Miami,FL 33126

  • Online Intake Form

  • Format: (000) 000-0000.
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  • Medical History

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  • Medical Condition

  • Current Condition of the Scalp

  • Do you have dandruff?*
  • Do you have scalp fungus?*
  • Have you noticed hair loss?*
  • Are you currently using any hair product or treatment?*

  • Previous Hair Procedures

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  • Previous Hair Procedures

  • Patient Declaration

  • AUTHORIZATION AND CONSENT FOR USE OF PHOTOGRAPHS AND VIDEOS

  • Patient Agreement: Growth Guarantee, Warranty, and Refund Policy

  • 1) Purpose of This Aggreement

    This agreement is designed to provide support and protection to patients as consumers, safeguarding dignity, rights, and well-being. Belleza Esthetic Center is committed to clear, safe, and professional care, encouraging freedom of choice, and ensuring a reliable experience at every stage of treatment.

  • 2) The Belleza Growth Guarantee (Progress Guarantee)

    Belleza does not guarantee “perfect hair,” a specific density, or a particular cosmetic outcome.

    What is guaranteed:
    By month 10, the patient will have visible hair growth progress in the transplanted areas, meaning:

    • New hairs are emerging
    • Coverage is visibly improved compared to pre-operative appearance
    • Transplanted graft activity is visibly apparent

    If visible progress is not present by month 10, Belleza will provide:

    • Complimentary in-clinic evaluation
    • PRP + CGF booster session
    • Priority doctor review
    • Return flight voucher for the evaluation visit

  • 3) What Is Not Guaranteed (Important)

    The following are not guaranteed:

    • Exact density outcome
    • Hairline shape perfection
    • Final cosmetic appearance
    • Growth timeline earlier than month 10

    The patient understands results may vary depending on individual response, donor quality, genetics, lifestyle habits, and compliance with post-operative care.

  • 4) Conditions Required for the Guarantee and Warranties

    The patient agrees to the following conditions, which are required to activate the Growth Guarantee and warranties:

    4.1 Prior Medical Evaluation
    Patient must undergo a complete medical evaluation to determine suitability based on medical history, hair characteristics, and realistic expectations.

    4.2 Informed Consent
    Patient must sign informed consent acknowledging understanding of risks, care instructions, expected results, and treatment limitations.

    4.3 Mandatory Care Instructions
    Patient must comply with all post-operative medical instructions. Failure to comply may affect results and may void the warranties and/or guarantee coverage.

    4.4 Medical Restrictions
    Treatment is not recommended for individuals with active dermatological diseases, autoimmune disorders, bleeding/clotting disorders (coagulopathies), infections, or any condition that in medical judgment poses a risk.


    4.5 Photo Documentation for the Growth Guarantee
    To evaluate “visible progress,” the patient agrees to submit required photo documentation at months 0, 6, and 10, following Belleza photo guidelines, and to communicate promptly if anything unusual occurs.

  • 5) Deposit, Scheduling, Rescheduling, and Refund Policy

    5.1 Deposit and Scheduling
    To reserve and schedule a surgery date, the patient agrees to pay a minimum deposit which varies based on package.

    5.2 Rescheduling
    Appointments may be rescheduled as long as the clinic is notified at least 5 business days in advance.

    5.3 Non-Refund Policy
    If the patient decides not to undergo the procedure after making the deposit, no refund will be issued under any circumstances.

  • 6) Acknowledgment

    By signing below, the patient acknowledges they have read and understood this agreement, including the conditions of the Growth Guarantee, the service warranties, the conditions required for coverage, and the deposit/rescheduling/non-refund terms.

  • Date*
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