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CONSENT FOR TREATMENT AND AUTHORIZATION TO COLLECT PAYMENT

 

    

Elizabeth Adams, M.D., LLC

Consent for Treatment and Authorization to Collect Payment

 

I Agree
I authorize Dr. Elizabeth Adams to provide professional cosmetic, aesthetic and wellness treatments.  I understand that I am seeking these services for consultation purposes only.  If additional treatment is required due to an adverse response to a particular procedure or treatment service, I authorize Dr. Adams to perform the recommended treatment, but I understand that I am free to choose another provider to furnish such treatment or render a second opinion if the response is non-emergent.

 

I Agree
I understand that Dr. Adams is NOT my primary care physician (PCP) and is not responsible for the diagnosis and treatment of any medical disorder, but instead is offering professional services that are cosmetic only in nature.  I understand that I must maintain a PCP to continue with all available conventional measures to attend to any medical condition for which I require continued monitored or interventional medical care.  

 

I Agree
I understand that should I have an adverse reaction to any procedure or treatment provided by Dr. Adams after leaving the facility, and if it is serious, I will seek emergency care immediately from a qualified medical facility or my own doctor.  I will also report to her, any and all unfavorable reactions that occur.  I understand that Dr. Adams is completely office-based and she does not admit to a hospital, is not affiliated with any hospital or insurance company, and she does not provide emergency, on-call services.

 

I Agree
 I understand that the services provided by Dr. Adams are cosmetic and are not reimbursed by my health insurance.  

 

I Agree
 I also understand that Dr. Adams does not participate in any insurance plans, including Medicare, her services may NOT be billed to OR submitted for reimbursement by Medicare, Medicaid or any other insurance plan, and that I am responsible for payment, prior to each service. I am also solely responsible for all charges for all treatment and procedures.  

 

I Agree
 I agree to pay for all services prior to each visit. On the occasion that I have an outstanding balance owed Dr. Adams, I agree to pay for all costs and expenses, including, but not limited to, court costs, attorney fees, and interest, if it is necessary to secure such payment. 

 

I Agree
 I understand there is a cancellation fee of $50 for missed appointments that are not cancelled more than 24 hours in advance. This fee must be paid prior to next appointment. I understand the full charge of the visit is due for any appointments that are missed and not given prior notification. This fee must be paid prior to next appointment.

 

I Agree
I authorize permission for Dr. Adams to communicate regarding my healthcare to me or any authorized recipient by various technologies including, but not limited to: emails, text messages and voicemail.

 

I Agree
I understand that there is no guarantee of results or outcomes of any procedures or treatments rendered by Dr. Adams.  

 

I Agree
I have read and understand the nature of the services provided by Dr. Adams. It is my prerogative to revoke, in writing, at any time the authorizations contained in this document.  Such revocation, does not relieve my financial responsibility to pay for services already provided to me by Dr. Adams and her staff.  I also declare that I am here to receive cosmetic and aesthetic services only, and for no other reason.

 

I hereby acknowledge that I have read this Consent for Treatment and Authorization to Collect Payment, and that I fully understand and agree to its terms.  I am signing this consent freely and voluntarily.


 

 

 

First Client's Name

First Name*

Last Name*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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