Medical Spa Patient Paperwork

    Due to the HIPAA (Health Insurance Portability and Accountability Act) all information must be completed on this form and the following forms. If you have any questions regarding this, anyone in our office will be glad to help you.
    *All fields are required.

    Patient Information

    Full Legal Name

    Emergency Contact


    Patient Signature (or Parental Signature if under 18)

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    Medical Spa Profile and Assessment

    We ask that all patients complete this profile prior to receiving any service. We use this information to accurately evaluate our patient’s specific needs. This info is completely confidential and used for analysis purposes only.

    1. Current Health Issues (check all that apply)

    2. Skin Issues (check all that apply)

    3. Which steps do you include in your home regimen:

    4. List current Medications (past 30 days):

    5. Have you experienced an allergic reaction to:

    6. Fitzpatrick Skin Type (check your type):

    I confirm that to the best of my knowledge, the answers I have given are correct and I have not withheld any information. I will inform my practitioner of any changes in my health or lifestyle which may affect my treatments.


    St. Louis Cosmetic Surgery Medical Spa
    17300 N. Outer 40 Road, Suite 300
    Chesterfield, MO 63005
    The Health Insurance Portability and Accountability Act of 1996 ("HIPAA") is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used.
    "HIPAA" provides penalties for covered entities that misuse personal health information.
    As required by "HIPAA" we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your information.
    We may use and disclose your medical records only for each of the following purposes: treatment, payment and healthcare operations.
    • Treatment means providing, coordinating, or managing healthcare and related services by one or more healthcare providers. An example of this would include a physical examination.
    • Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and review. An example of this would be sending a bill for your visit to your insurance company for payment.
    • Healthcare Operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis and customer service. An example would be an internal quality assessment review.
    We may also create and distribute de-identified health information by removing all references to individually identifiable information.
    We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
    Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken action relying on you authorization.
    You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:
    • The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosure to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
    • The right to reasonable request to receive confidential communication of protected health information from us by alternative locations.
    • The right to inspect a copy of your protected health information.
    • The right to amend your protected health information.
    • The right to obtain a paper copy of this notice from us upon request.
    We are required by law to maintain the privacy of your protected health information and to provide you with notice of legal duties and privacy with respect to protected health information.
    This notice is effective as of April 1, 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post, and you may request a written copy of a revised Notice of Privacy Practices from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our Privacy Officer, or upon request we will supply you with the address of the Department of Health & Human Services, Office of Civil Rights to file a written complaint. We will not retaliate against your filing a complaint.


    St. Louis Cosmetic Surgery Medical Spa
    17300 North Outer Forty Road, Suite 300
    Saint Louis, MO 63005
    Phone: 636-530-9020
    Fax: 636-777-7500
    I understand that, under the Health Insurance Portability & Accountability Act of 1966 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
    • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
    • Obtain payment from third-party payers.
    • Conduct normal healthcare operations such as quality assessments and physician certifications.
    I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the above address to obtain a current comp of the Notice of Privacy Practices.
    I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.


    I request that all communications to me (by telephone, mail or otherwise) by St. Louis Cosmetic Surgery, Inc., and/or its staff be handled in the following manner:
    If you are unavailable at this number, may we leave an answering machine or voice mail message?
    Do we have permission to disclose your health information with another person other than yourself?

    Informed Consent for Care

    Any questions you have regarding the nature and purpose of your treatment(s) and/or procedure(s) will be discussed and explained to your satisfaction.
    My signature acknowledges that I have read the following:
    I, (signature), consent to and authorize the staff of St. Louis Cosmetic Surgery Medical Spa to perform treatments as discussed between myself and my practitioners.

    Please INITIAL each statement after you have read and agreed to it:

    (initial) I understand that with any treatment, certain risks are involved and that any complications or side effects from known or unknown cause could occur. I freely assume these risks.
    (initial) I have stated all medical conditions of which I am aware and will inform my practitioner of any changes in my health status or routine.
    (initial) You will be notified if your specific treatment may include any alternate side effects.
    (initial) I agree to adhere to all safety precautions and home skin care programs as recommended by my practitioner.
    (initial) I will contact the Medical Spa to inform my practitioner of any complications or concerns I may have as soon as they occur. If no one is available, I will leave a message with my contact information detailing my issues.

    Photographic Consent Agreement and Release

    St. Louis Cosmetic Surgery Medical Spa desires to photograph treated areas of each patient before and after rendering aesthetic services to document improvement in the appearance of treated areas.
    • Skin care patients may have a Visia image made of their full-face to evaluate skin condition, determine proper care, and to document improvement.
    • Some specific treatments require full-face photographs
    • St. Louis Cosmetic Surgery Medical Spa agrees NOT to use patient’s name together with their full-face photograph(s) without separate, express written consent.
    Before and After photos are required for most Medical Spa treatments. Patient agrees to allow St. Louis Cosmetic Surgery Medical Spa to take photographs of the treatment area for your PRIVATE medical file. (initial)
    In addition to the above, please initial next to each usage described below that you agree to allow us permission to use your photographs. Leave blank if you do not agree:
    (initial) Educational presentations
    (initial) Portfolio of results to be shown to patients
    (initial) Web site
    Patient does hereby release St. Louis Cosmetic Surgery Medical Spa, now and forever, from any liability or claim for damages resulting from the above authorized use of said photographs.


    (initial) I, the undersigned patient, consent to an in-person consultation and/or to have my Doctor and/or his/her staff (hereinafter collectively “my Doctor”) perform medical procedures, whether regarded as necessary, elective or aesthetic, during the time of the COVID-19 pandemic and after. I understand in-person consultations and/or having my procedure performed at this time, despite my own efforts and those of my Doctor, may increase the risk of my exposure to COVID-19. I am aware that exposure to COVID-19 can result in severe illness, intensive therapies, extended intubation and/or ventilator support, life-altering changes to my health, and even death. I am also aware of the possibility that the procedure itself, whether performed in my Doctor’s office or in a hospital, may result in a more severe case of COVID-19 than I might have had without the procedure.
    (initial) I also understand in-person consultations and/or having my procedure performed at this time increases the risk of my transmission of COVID-19 to my Doctor. This virus has a long incubation period, there may be as yet unknown aspects of its transmission, and I realize that I may be contagious, whether or not I have been tested or have symptoms. To reduce the possibility of COVID-19 exposure or transmission at my Doctor’s office, I accept that my Doctor will implement infection-control procedures with which I must comply, before, during and after my consultation and/or procedure, for my own protection as well as that of my Doctor. I understand my cooperation is mandatory, whether or not I personally feel such COVID-19 procedures and/or preventive measures are necessary.
    (initial) I have informed my Doctor of any COVID-19 testing I or any person living with me during the past 14 days has received, as well as the results of that testing, and if I am tested between now and the date of my procedure, I will immediately provide the results of that testing to my Doctor. I understand my Doctor may require that I be tested, possibly at my own expense and regardless of any prior testing, and that the results of that testing must be satisfactory to my Doctor, before I may receive my procedure. I understand I must honestly disclose this information to avoid putting myself and others at risk.
    (initial) All topics above have been discussed with me, and all my questions have been answered to my satisfaction. Being fully informed, I accept the risk of COVID-19 exposure and I will bear the cost of any COVID-19 treatments required. I have been given the opportunity to postpone my in-person consultation and/or procedure until the COVID-19 pandemic is less prevalent, but I choose to have my in-person consultation and/or procedure performed now. If I am the parent, guardian or conservator of the patient, I hold his/her health care power of attorney. I have read this COVID-19 Informed Consent Agreement and am authorized to consent on the patient's behalf.


    Notice and Disclaimer. Medical information changes constantly. This COVID-19 Informed Consent Agreement sets forth the current recommendations of The Aesthetic Society, is provided for informational purposes only, and does not establish a new standard of care.
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