Post-Op Care Client Release and Commitment Form
I agree to keep all appointments as scheduled.
I understand and acknowledge all missed appointments are not made up and there is no refund on that specific appointment.
I consent to be measured on all my appointments for the purpose of recording changes in target areas for improvement in healing.
I will consent to being photographed every third session for the purpose of recording changes in my target areas for improvement and healing.
I will report any significant health issue that may occur during my post op care cosmetics bar program to include any drainage of fluids from drainage points.
I am aware that all files photographs and
measurements are the property of the certified postop surgical care provider.
I give permission for the post op surgical care provider to publish statistical data and photographs derive from my post op care service.
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature
Date
-
Month
-
Day
Year
Date
Witness Signature
Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Submit
Should be Empty: