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Your information is confidential and is saved to your account. A copy of this form is available upon request.
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.
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.
Purpose of This Consent Form
The purpose of this form is to inform you of the potential benefits, risks, and alternatives associated with aesthetic and wellness treatments provided by Bloom Health. These may include, but are not limited to, injectable treatments (such as neuromodulators and dermal fillers), microneedling, laser or light-based therapies, chemical peels, facials, and energy-based or regenerative procedures. Please read each section carefully and discuss any questions with your provider before signing.
Treatment Goals and Description of Procedure
Bloom Health offers non-surgical aesthetic and wellness treatments designed to improve the health and appearance of the skin and body. While these treatments can enhance your overall appearance and well-being, they are not medical necessity procedures and outcomes vary from person to person. Your provider will recommend a personalized treatment plan based on your goals, skin type, and medical history.
Treatment Results
Many clients experience visible improvement after a single treatment, while others may require a series of sessions to achieve optimal results. Results are not guaranteed and may vary based on individual skin condition, lifestyle factors, and adherence to aftercare recommendations. Maintenance treatments may be needed to sustain results.
Aftercare Instructions
Your provider will review aftercare instructions during your visit. Proper adherence to these guidelines is essential to minimize complications and maximize results. Notify Bloom Health immediately if you experience unusual pain, prolonged redness, swelling, or signs of infection.
Potential Risks and Complications
While Bloom Health treatments are generally considered safe and low-risk, all procedures carry potential side effects. These may include but are not limited to: 1) Redness, dryness, peeling, irritation, swelling, or discomfort; 2) Post-inflammatory hyperpigmentation or hypopigmentation; 3) Acne breakouts or milia; 4) Reactivation of cold sores (herpes simplex virus); 5) Rare risk of infection, scarring, or burns; 6) Unsatisfactory results or asymmetry. Adherence to aftercare is essential to minimizing risk.
Pregnancy and Contraindicated Conditions
I am not aware that I am pregnant. I am not trying to get pregnant. I am not currently breastfeeding. I have notified my Bloom Health provider of any medical conditions, medications, or recent facial treatments. I do not have any open wounds, infections, or history of keloids in the treatment area. I do not have a history of light-triggered seizures or photosensitive disorders. I am not taking any medications that increase sensitivity to light (e.g., isotretinoin, doxycycline).
Alternative Therapy
Alternatives to treatment include topical skincare, other aesthetic procedures, or choosing not to undergo treatment at all. Your provider will discuss which options may be appropriate for your goals and medical background.
Payment
All treatments performed at Bloom Health are elective and not presumed to be covered by insurance. Payment is required at the time of service. Because results vary, no refunds or guarantees can be provided once treatment has been rendered.
Right to Discontinue Treatment
I understand that I have the right to discontinue treatment at any time.
Release of Liability
I hereby release and hold harmless Bloom Health, PLLC and its affiliates from any liability associated with this elective treatment. I understand that all questions and post-treatment concerns should be directed to my Bloom Health provider. I understand that my provider is licensed and trained to perform this procedure and that outcomes may vary.
Consent to Treatment
By entering my initials below, I voluntarily consent to receive treatment as performed by my Bloom Health provider. I acknowledge that I have read and understand the above. I am not under the influence of drugs or alcohol, and all of my questions have been answered to my satisfaction. I understand the risks and benefits of this elective procedure. This consent applies to all future treatments I choose to receive at Bloom Health.
