Patient Consent For Delivery & Payment

Patient Consent For Delivery & Payment (Form 3/4)

Please note, appointment reminders will be sent via text message to your cell phone. You will also receive a phone call or email to follow-up on first-time treatments.

By placing my signature below, I freely give the physicians and healthcare providers at the Washington Institute of Dermatologic Laser Surgery permission to treat my condition. I further understand that I will be charged/billed for consultations, treatments, and missed, or rescheduled appointments per office policy. A nonrefundable charge of $250 will be charged for each missed appointment or for every appointment canceled or rescheduled within 48 business hours.

There is a nonrefundable deposit of $1,000 required for the following procedures at the time of scheduling: CO 2 Laser, Coolsculpting, Instalift, Thermage, Ulthera.

I understand the the payment/billing policy.

I consent for clinical photographs to be taken as prescribed by my treating physician at any time during my care. I understand that the photos will be accorded the same privacy as my medical chart and that my consent can be withdrawn at any time (even after signing this consent form). I further understand that baseline (pre-treatment) and follow-up (post-treatment) photographs are essential to document my clinical progress and therapeutic response.

I give my consent of photographs as outlined above.

Who is authorized to receive patient medical information?

Patient

Physician

Family Member

Physician/Family Member Name & Relationship

It is the patient’s responsibility to notify the office in writing with any changes to the information above.
Washington Institute of Dermatologic Laser Surgery does not participate with insurance companies.
Our physicians and staff members do not testify in court depositions, arbitrations, etc. relating to Worker’s Compensation or any other personal injury claims.
Full payment is required at the time of services rendered. Payment for services is solely the patient’s responsibility at (or before) the time of service.

By placing my signature below, I consent with the information provided above and freely give the physicians and other healthcare providers at the Washington Institute of Dermatologic Laser Surgery permission to treat and photograph my condition(s). I agree to forego social posts (anonymous or otherwise) with any negative or defamatory remarks. I understand that my privacy will always be protected.

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