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HIPAA PRIVACY NOTICE
Bloom Health maintains compliance with the Health Insurance Portability and Accountability Act (HIPAA). HIPAA provides certain rights and protections to you as the patient, including protection of your Personal Health Information (PHI). HIPAA sets forth rules and restrictions on who has access to your PHI. If you'd like to view our HIPAA policy in its entirety, please click
here. By clicking YES below, I acknowledge this privacy notification.
GENERAL CONSENT TO TREATMENT
I verify that I have read and fully understand this questionnaire. I have responded to the questions truthfully. I understand that withholding information or providing misinformation may result in unforeseen side effects or complications. I am aware that it is my responsibility to inform Bloom Health and my treating provider of any updates to my health history. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. While all treatments are recommended to achieve the best possible results, I understand that not all treatments will have the same result for every client, therefore no guarantee can be given. The treatments I receive from Bloom Health are voluntary and I release Bloom Health, PLLC from liability and assume full responsibility thereof.
INFORMED CONSENT FOR BH SIGNATURE FACIAL
The purpose of this section is to provide written information regarding the risks, benefits and alternatives of treatment with BH Signature Facial. This material serves as a supplement to the discussion you have with your Bloom Health provider. It’s important that you fully understand this material, so please read this information thoroughly. If you have any questions regarding the treatment, ask your Bloom Health provider prior to submitting this consent form.
Treatment Goals and Description of Procedure
BH Signature Facial is a customized skin treatment that combines cleansing, exfoliation, extraction, and hydration, resulting in clearer, more beautiful skin with little-to-no downtime. The treatment is soothing, moisturizing, non-invasive and generally non-irritating. BH Signature Facial is customized to your skincare goals with addition of booster serums, LED light therapy, lymphatic drainage, and other Add-Ons as needed.
Treatment Results
Most patients are pleased with the results of their BH Signature Facial treatment. However, like any aesthetic procedure, there is no guarantee that you will be completely satisfied. Multiple treatments are needed to achieve a continuous effect, with a usual recommendation of monthly treatments, spaced 4 weeks apart. The results of treatment are dependent on many factors including but not limited to: age, tissue conditions, and your general health and lifestyle conditions. Results are visible immediately after your treatment. Although highly unlikely, it is possible that you will not achieve any noticeable result from the procedure.
Aftercare Instructions
Following your BH Signature Facial treatment, we’ll provide you with verbal and/or written aftercare instructions. These include, but may not be limited to the following: 1) You may resume normal activities immediately following the procedure; 2) You may experience temporary skin redness, irritation, or tightness for up to 72 hours; 3) You may experience tingling and stinging in the treatment area, these sensations generally subside within a few hours; 4) The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen; 6) If at any time you suspect you’re having an unexpected side effect, adverse reaction or complication, contact us immediately, and obtain help in an appropriate medical setting (i.e., Bloom Health, your primary care provider, specialist, urgent care, or acute care facility). I will adhere to the aftercare instructions supplied to me during my visit.
Potential Risks and Complications
Before undergoing this procedure, understanding the risks is essential. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate extended outpatient therapy, or in extremely rare cases hospitalization. I understand that there are certain inherent and potential risks and side effects in any procedure, and in this specific instance such risks include but are not limited to: 1) Treatment site reactions, including redness, skin tightness, and pain; 2) Susceptibility to sunburn/sun damage; 3) Allergic reaction to the ingredients in skincare products; 4) Worsening of cold sores or existing skin lesions.
Pregnancy and Contraindicated Conditions
I am not aware that I am pregnant. I am not trying to get pregnant. I am not lactating (nursing). I have notified my Bloom Health provider of any recent skin treatments or skin problems. I do not have any difficulty swallowing or any bleeding problems. I am not on anticoagulants or antiplatelet medications. I do not have known sensitivity to usual skincare ingredients. I do not have an infection in the treatment area.
Alternative Therapy
I understand that this is an elective procedure with goal of improved aesthetic appearance and that the main alternative to therapy is to observe and not receive any treatment. Alternative therapies to this treatment might include microdermabrasion, chemical peel, laser resurfacing, or plasma facial.
Payment
I understand that BH Signature Facial is not covered by insurance, and payment is my responsibility and is expected at the time of treatment.
Right to Discontinue Treatment
I understand that I have the right to discontinue the procedure at any time.
Release of Liability
I hereby indemnify Bloom Health, PLLC from any liability relating to the procedures that I have volunteered for. I understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-treatment questions or concerns to the treating clinician. Furthermore, I hereby indemnify the facility/meeting room/hotel where this treatment is being performed from any liability relating to the procedures that I have volunteered for.
Consent to Treatment
By entering my initials below, I hereby voluntarily consent to BH Signature Facial for the purpose of skin rejuvenation, smoothing, and brightening in the facial area or other planned areas, as performed by my Bloom Health provider. I have read the above and understand it. I state that I read and write in English. I am not under the influence of drugs or alcohol. The treatment has been fully explained to me and my questions have been answered satisfactorily. I accept the risks and complications of this elective procedure and I understand that no guarantees are implied as to the outcome of the procedure. Please note this consent is valid for all future BH Signature Facial treatments I choose to receive from Bloom Health.
