Spa Informed Consent form
FYI: To be placed in front office reception area and also each chart, signed by patient yearly
along with lined signature page each visit.
Dear J Beauty Studio Med spa Patient,
In adherence with Board Rule 1.17 and HB 25-1024, our spa Eunjoo Lee and its Medical Director, Michael R. Iannotti, MD, are offering you medical grade aesthetic services delegated from a Physician to licensed and unlicensed persons/delegatees who are trained and certified.
This notice is to inform you of the following, all standard and usual and customary according to the Board Rule and HB:
1. Michael R. Iannotti, MD is our Medical Director, Board Certified in Family Medicine and
extensively trained in medical grade aesthetic consultations and procedures, and
2. Dr. Iannotti delegates his licensure and authority to practice to the contractors/employees,
licensed and unlicensed, of this aesthetic spa, so he/she may provide services to you today, such
that the licensed and unlicensed persons are trained and certified and delegated authority by a licensed Physician, and
3. Any delegatee whom practices outside of his/her scope of practice, does so per Dr. Iannotti’s authority with training and advanced certification from third party agencies, and
4. Dr. Iannotti is available for pre-procedure advice, consultation or post-procedure advice,complication treatment, remedy or consultation and his phone number is: 303-929-9771 and his email is: iannotmr@hotmail.com.
5. Patients may file complaints at DORA,
6. Copy of this information may be also found at this medi spa website.
7. Copy of this informed consent will be posted in the reception area/room of the medi spa and also saved with the medical chart for seven (7)years total. After seven (7) years, patient charts may be destroyed by state law.
We hope you find your services outstanding today.
Respectfully,
J Beauty Studio Med Spa Owner Eunjoo Lee
And
Michael R. Iannotti MD, Medical Director, Co License 39567 Email: iannotmr@hotmail.com,
phone 303-929-9771