Financial Responsibility & Consent Agreement

To provide the highest quality physician-directed care, we ask every patient to review and acknowledge the following information before treatment.

Financial Responsibility

I understand that cosmetic and aesthetic treatments are elective medical services.

Payment is due at the time services are rendered unless otherwise agreed.

I agree to remain financially responsible for all services provided.

Cosmetic Treatments

I understand that cosmetic procedures are individualized medical treatments.

No guarantees or warranties have been made regarding:

• cosmetic outcome 
• degree of improvement 
• duration of results 

Treatment Recommendations

I understand that treatment recommendations are based upon:

my medical history,

physical examination,

physician judgment,

current scientific evidence,

and my individual goals.

I understand that I may decline any recommended treatment.

Risks & Alternatives

I understand that every medical procedure carries potential risks, side effects, and complications.

These will be discussed before treatment.

I understand that alternative treatments, including no treatment, may also be appropriate.

Medical Information

I certify that the medical information I provide is complete and accurate.

I agree to notify LumiLife if my medical history, medications, allergies, or health status changes before treatment.

Photography

Clinical photographs may be taken for documentation, treatment planning, and monitoring progress.

These photographs become part of my confidential medical record.

Separate written authorization is required before any photographs are used for educational or marketing purposes.

Financial Policies

I acknowledge receiving and agreeing to:

• Appointment Policies 
• Cancellation Policy 
• Membership Policies (if applicable) 
• Refund Policy 

Results

I understand that aesthetic medicine is not an exact science.

Results vary among individuals.

Additional treatments or maintenance may be recommended.

Consent

I have had the opportunity to ask questions.

My questions have been answered to my satisfaction.

I voluntarily consent to evaluation and treatment at LumiLife Aesthetics + Wellness.

Patient Name

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Patient Signature

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Date

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Physician Signature

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Date

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