Patient Consent to
Treatment and Procedures

PLEASE READ EACH SECTION CAREFULLY. YOU MAY REQUEST A COPY OF THIS FORM FOR YOUR RECORDS.

I, the undersigned, request and consent to evaluation and treatment by PREEMA, its affiliated professional entities, and staff (collectively, “PREEMA”). I understand that PREEMA will use its professional judgment to provide care in my best interest, including any related procedures performed. I will inform PREEMA of any relevant health conditions or concerns before, during, or after treatment. This consent applies to the full course of treatment and any related procedures.

I acknowledge that I have had the opportunity to ask questions regarding the treatment, alternatives, side effects, and potential complications, and that all questions have been answered to my satisfaction by PREEMA’s clinical staff.

I understand that medical and aesthetic services are not an exact science and that payment is for the performance of services, not a guaranteed outcome. While PREEMA makes every effort to set realistic expectations, no warranty—express or implied—is provided regarding results.

Treatment Disclosure and Acknowledgment

The nature of the treatment or procedure has been explained to me, and I have separately consented to receive care through PREEMA. I understand all medical procedures carry inherent risks in addition to potential benefits.

Telehealth and Pharmacy Services

PREEMA may offer telehealth services that allow me to consult with licensed health care professionals via electronic communication. These services may include online consultations, prescription services, and health evaluations without in-person visits.

Telehealth involves:

Electronic transmission of medical records, images, and health information.

Real-time or asynchronous communications (e.g., secure messaging, email, video calls).

Use of data from medical devices, remote monitoring, and digital files.

PREEMA utilizes secure systems to protect the privacy and integrity of your health information.

Potential Benefits

Greater convenience and accessibility to medical care.

Reduced need for in-person appointments.

Remote consultations for certain conditions without requiring a physical exam.

Potential Limitations

Limitations in assessing conditions without an in-person exam.

Technical issues may delay or interrupt care.

Data security risks inherent in electronic communications.

Prescriptions and treatments may be limited by state or local laws.

Consent Acknowledgment for Telehealth

By signing below, I acknowledge the following:

I understand emergency care is not available through telehealth. If I experience a medical emergency, I will call 911.

I consent to receive medical care via telehealth.

I understand technical issues may delay or interfere with care or data.

I understand results from treatment are not guaranteed.

I have a responsibility to provide complete and honest medical history.

My provider may determine telehealth is not appropriate for my condition.

PREEMA does not replace existing relationships with my primary care providers.

My health information will be used and protected in accordance with PREEMA’s Privacy Policy.

I can request that my telehealth records be shared with other providers upon request and written consent.

Payment Obligation for Treatment

I understand that services offered by PREEMA are elective, and I am responsible for full payment at the time of service. Missed appointments or cancellations with less than 24 hours' notice may incur a no-show fee. It is my responsibility to manage my appointments, regardless of reminder messages.

PREEMA Refund Policy

PREEMA does not guarantee results and therefore does not issue refunds for treatments performed in accordance with its professional standards. Concerns regarding treatments should be directed to your provider or the clinic manager for review by PREEMA management.

Consent for Photography for Treatment Purposes

I consent to photographs, videos, audio, and other forms of image recording (“Photography”) being taken for documentation and healthcare purposes. I understand:

These recordings assist in my treatment and PREEMA’s health operations.

They may become part of my medical record and are protected under PREEMA’s Privacy Policy.

PREEMA owns these recordings, though I may access or request copies of what becomes part of my medical record.

A separate written consent will be required for any non-medical or marketing use of my photographs.

Acknowledgement and Agreement

I understand that treatment is voluntary and elective, and I may stop at any time. The procedure has been explained to me, including alternatives, and no guarantees have been made.

I have disclosed all known allergies, current medications, and relevant health information. I understand the potential risks, side effects, and that my condition may improve, remain the same, or worsen.

I certify that I am at least 18 years of age and voluntarily consent to the treatments and procedures described above.