AUTHORIZATION TO DISCLOSE HEALTH INFORMATION

Use this form to request an itemized copy of your healthcare records with Mirza Aesthetics. Unless otherwise indicated, only the most recent records will be included. 

BRILLIANT DISTINCTIONS® MEMBER ID

In the event that you were unable to notate your ID during your visit to the office, and if you are currently enrolled in the Allergen-sponsored Brilliant Distinctions program, you may use this form to update your member ID. Points can only be issued retroactively up to 2 months.

CONSENT TO TREAT

By signing this form, you consent to treatment by Mirza Aesthetics; and acknowledge that because every individual is different, results from aesthetic services cannot be guaranteed.

OTHER QUESTIONS OR CONCERns

Use this form to submit any other questions you may have regarding your treatment. Please allow up to 3 business days for a response.