Patient Discharge Form

Patient Name *

First Name Last Name

Date Discharged *

Date

Please describe the treatment the patient received: *

Reason for Discharge *

Patient was Fully Treated Patient Non-Compliance Rude or Threatening Behavior Non-Payment of Fees Failure to Keep Appointments

Was our post-care consent form presented to the patient? *

Yes No

Discharging Staff Member

First Name Last Name

Patient Signature

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I understand that although good results are expected, there cannot be any guarantee or warranty, expressed or implied, that I will be completely satisfied by the outcome or that I will not require additional treatment and/or ongoing treatment to achieve the result I seek. I understand that treatments will not cure any medical conditions nor provide immunity against re-occurrence of such conditions. The treatments are temporary and very per patient with some patients experiencing shorter or longer effects. The number of treatments needed varies per patient and may be affected by the following factors including but not limited to: degree of skin irregularity; severity of volume loss; patient age; personal medical profile; basic metabolic rate; previous cosmetic procedures; history of trauma to the treated area; individual lifestyle choices; and individual patient preference. I understand that all product and service sales are final. No refunds on services or products. I have read and understand all information presented to me before signing this consent form. I have been given an opportunity to have all of my questions answered to my satisfaction. I understand the procedure and accept the risks. I agree to the terms of this agreement. Except where prohibited by law; I acknowledge and voluntarily assume the risk of injury, accident or death which may arise from the use of any skincare products or services preformed by Halo Med Spa. I agree Halo Med Spa will not be liable for death or any injury, including, without limitation, personal, bodily or mental injury, economic loss or damage to me resulting from negligence, other acts in Halo Med Spa, anyone acting on Halo Med Spa's behalf, or anyone using the services of the facilities of Halo Med Spa, to the fullest extent permitted by law. This agreement together with Halo Med Spa's post-care plan rules and regulations, constitute the entire agreement between you and us and cannot be amended, except in writing by both parties. Myself and/or any of my heirs, executors, representatives, or assignees hereby release Halo Med Spa from all claims or liabilities for death, personal injury or property loss or damages of any kind sustained while on the premises. I agree that this form and waiver is in effect for all services offered by Halo Med Spa, and will not expire unless specifically requested by either party. I understand that Halo Med Spa is a tranquil and professional environment and that any inappropriate behavior may result in termination of my services and full payment is expected. I also understand that any medical device used by the patient outside of Halo Med Spa care or failing to list or mention such medical devices could result in unexpected or unwanted results. By signing this form, I agree to the above terms and release Halo Med Spa and its employees from any liability. *

I understand & I agree

Medical Staff Signature

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