Plastic Surgery Patient-Provider Agreement and Informed Consent

1. Parties Involved

This agreement is made between:

• Provider: [Practice Name], [Address]
• Surgeon: Dr. [Name], Board Certified Plastic Surgeon
• Patient: [Patient Full Name], [DOB]

2. Scope of Services

Proposed Procedure(s)

• Primary procedure: [Procedure Name]
• Additional procedures: [If applicable]
• Estimated duration: [Time]
• Proposed date: [Date]

3. Financial Agreement

Fees and Payment

• Total procedure cost: $[Amount]
• Deposit required: $[Amount] (non-refundable)
• Payment schedule: [Details]
• Insurance coverage: [If applicable]

4. Informed Consent

Understanding of:

• Expected outcomes and limitations
• Potential risks and complications
• Alternative treatment options
• Recovery process and timeline
• Post-operative care requirements

5. Photography Consent

• Pre-operative documentation
• Post-operative documentation
• Usage rights and limitations
• Patient privacy protection

6. Cancellation Policy

• Scheduling requirements
• Cancellation notice periods
• Deposit handling
• Rescheduling procedures

7. Post-operative Care

• Follow-up appointment schedule
• Emergency contact information
• Care instructions compliance
• Medication requirements

8. Acknowledgment

I, [Patient Name], have read and fully understand this agreement. I have had the opportunity to ask questions and receive satisfactory answers.

Patient Signature / Date

Surgeon Signature / Date

Witness Signature / Date