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An image of a patient undergoing a Hydrafacial Booster Serum, a service offered at Bloom Health.
We'd Like To Get To Know You! Please Complete The Following Form​
Time to complete: about 5 minutes

Your information is confidential and will be saved to your account. A copy of this form is available upon request.



























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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 WEIGHT LOSS THERAPY
The purpose of this section is to provide written information regarding the risks, benefits, and alternatives of weight loss therapy. 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
Weight loss therapy at Bloom Health is a medically supervised program that may include lifestyle modifications, nutritional guidance, exercise recommendations, prescription medications, injectable therapies, and/or other treatments designed to promote weight loss. The specific treatment plan is customized to your individual health profile and weight loss goals. While many patients experience positive outcomes, results vary based on adherence to the program, metabolic factors, and other individual health conditions.

Treatment Results
Most patients experience weight loss and improvements in their overall health with consistent adherence to the treatment plan. However, like any medical or aesthetic procedure, there is no guarantee that you will be completely satisfied with the results. Multiple treatments, lifestyle modifications, and continued medical supervision may be required to achieve and maintain weight loss. The rate and extent of weight loss are influenced by factors such as age, metabolism, diet, exercise, medical history, and lifestyle habits. Although rare, it is possible that you may not achieve significant weight loss despite following the recommended treatment plan.

Aftercare Instructions
Following your weight loss therapy, we’ll provide you with verbal and/or written aftercare instructions. These include, but may not be limited to the following: 1) Adherence to dietary and lifestyle recommendations is crucial for optimal results; 2) You may experience temporary side effects such as nausea, dizziness, fatigue, or changes in bowel habits; 3) Staying hydrated and maintaining balanced nutrition is essential; 4) Certain weight loss medications or treatments may increase sensitivity to sunlight—use SPF 40 or higher if advised; 5) If at any time you experience unexpected side effects, adverse reactions, or complications, contact us immediately and seek medical attention as necessary (e.g., Bloom Health, your primary care provider, urgent care, or emergency medical services).

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 HydraFacial; 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 HydraFacial or it's ingredients. I do not have an infection in the treatment area.

Alternative Therapy
I understand that weight loss therapy is an elective program aimed at improving my overall health and aesthetic appearance. Alternatives to this therapy include lifestyle modification without medical supervision, bariatric surgery, or other medical interventions for weight management.

Payment
I understand that weight loss therapy 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 program at any time. However, I acknowledge that sudden discontinuation of certain medications or treatments may require medical guidance to avoid adverse effects.

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 weight loss therapy as outlined 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 program and understand that no guarantees are implied as to the outcome. This consent is valid for all future weight loss treatments I choose to receive from Bloom Health.

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