Patient Rights and Responsibilities Agreement

For Plastic Surgery Procedures and Treatment

Plastic Surgery

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Last updated: Mar 24, 2025

Your Rights as a Patient

Access to Care

  • Receive care regardless of race, gender, age, national origin, religion, or disability
  • Obtain complete information about your diagnosis, treatment, and prognosis
  • Access your medical records as permitted by law

Quality of Care

  • Receive safe, high-quality medical care from qualified professionals
  • Have your pain assessed and managed appropriately
  • Participate in all decisions about your treatment
  • Receive emergency care when needed

Privacy and Dignity

  • Have your privacy protected during medical consultations and procedures
  • Be treated with respect and consideration
  • Receive care in a safe, clean environment
  • Have all medical information kept confidential

Information and Communication

  • Receive detailed information about procedure costs and payment options
  • Know the names and roles of healthcare providers involved in your care
  • Get clear explanations about your condition and treatment options
  • Voice concerns without fear of discrimination

Your Responsibilities as a Patient

Providing Information

  • Supply accurate, complete medical history
  • Inform staff about current medications and supplements
  • Report unexpected changes in your condition
  • Provide accurate insurance and payment information

Following Treatment Plans

  • Follow pre-operative and post-operative instructions
  • Attend scheduled appointments
  • Participate actively in your recovery process
  • Complete recommended follow-up care

Financial Obligations

  • Meet financial commitments for care received
  • Provide current insurance information
  • Understand your insurance coverage
  • Arrange payment plans if needed

Facility Policies

  • Follow facility rules and regulations
  • Be respectful to staff and other patients
  • Arrive on time for appointments
  • Provide 24-hour notice for appointment cancellations

Acknowledgment

I have read and understand my rights and responsibilities as outlined above.

Patient Name: _________________ Date: _________________ Signature: _________________

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