Patient Discharge Form
Patient Name
*
First Name
Last Name
Date Discharged
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-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please describe the treatment the patient received:
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Reason for Discharge
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Patient was Fully Treated
Patient Non-Compliance
Rude or Threatening Behavior
Non-Payment of Fees
Failure to Keep Appointments
Other
Was our post-care consent form presented to the patient?
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Yes
No
Discharging Staff Member
First Name
Last Name
Patient Signature
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I understand that while good results are expected, there is no guarantee or warranty, either expressed or implied, that I will be completely satisfied with the outcome or that I will not require additional or ongoing treatment to achieve the desired results. I acknowledge that the treatments will not cure any medical conditions nor provide immunity against their recurrence. The effects of the treatments are temporary and can vary from patient to patient; some may experience shorter or longer-lasting effects. The number of treatments needed will vary based on factors such as: the degree of skin irregularity, severity of volume loss, patient age, personal medical history, metabolic rate, previous cosmetic procedures, history of trauma to the treated area, individual lifestyle choices, and personal preferences.I understand that all sales of products and services are final, and there are no refunds available. I have read and understood all the information presented to me before signing this consent form, and I have had the opportunity to ask questions to my satisfaction. I accept the risks involved in the procedure and agree to the terms of this agreement.Except where prohibited by law, I acknowledge and voluntarily assume the risk of injury, accident, or death that may result from the use of any skincare products or services performed by Halo Med Spa. I agree that Halo Med Spa will not be liable for any injury, including but not limited to personal, bodily, or mental injury, or economic loss resulting from negligence or other acts by Halo Med Spa, its representatives, or anyone using its services, to the fullest extent permitted by law.This agreement, along with Halo Med Spa's post-care plan rules and regulations, constitutes the entire agreement between us and cannot be modified unless in writing and signed by both parties. I, along with my heirs, executors, representatives, or assignees, hereby release Halo Med Spa from all claims or liabilities for death, personal injury, or property loss or damage of any kind sustained while on the premises.I understand that Halo Med Spa aims to provide a tranquil and professional environment, and any inappropriate behavior may result in termination of my services, with full payment expected. I also acknowledge that using any medical devices outside of Halo Med Spa’s care or failing to disclose such devices could lead to unexpected or undesirable results.If I sign up for a series of treatments, I must complete them within six months, unless otherwise noted and signed by both the provider and myself. Failing to complete the series within this timeframe will result in a 20% facility fee, although a Halo credit may be applied. I also understand that prepaid services are not transferable to another client of Halo Med Spa. If I choose to change my recommended program, I forfeit any discounts or special packages I may have received. I acknowledge that there are no refunds. By signing this form, I agree to the terms outlined above and release Halo Med Spa and its employees from any liability.
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I understand & I agree
Medical Staff Signature
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