Cosmetic Surgery Patient Confidentiality Agreement

Patient Name

Date of Birth

Address

Confidentiality Statement

I understand that all information related to my cosmetic surgery, including my personal data, medical history, treatment plans, before-and-after photographs, and any discussions held with the medical staff, will be kept strictly confidential in accordance with laws and clinic policy. This information will not be disclosed to others without my written consent, except as required by law.

Additional Comments or Restrictions (if any)

Acknowledgement & Signature

I have read and understood the above statement and agree to keep all discussions, observations, and documentation confidential as per the terms of this confidentiality agreement.

Patient Signature

Date

Witness Name

Witness Signature

Date