Beauty Consent for Treatment & Payment Acknowledgement
CONSENT TO MEDICAL/AESETHETIC CARE: The undersigned consents to any laboratory, imaging, aesthetic, medical, surgical or emergency treatment and/or clinic services rendered the patient under the instruction of the Provider. The patient understands that no guarantee or assurance has been made as to the results that may be obtained during treatment.
The client also consents to observation of the patient during administration of medical, aesthetic, surgical or diagnostic procedures of the purpose of education of students whose presence is deemed appropriate by the attending Provider.
RELEASE OF PATIENT INFORMATION: The undersigned hereby consents that Home Towne Beauty may release to the guarantor?s insurance company, or any third party payer, pertinent information related to the aesthetic treatment including: HIV testing and treatment, sexually transmitted disease testing and treatment, psychiatric, alcohol and drug treatment records in order to secure contractual payments of services rendered (unless a restriction has been requested, the see restriction agreement).
ASSIGNMENT OF INSURANCE BENEFITS: In the event the patient is entitled to medical benefits of any type whatsoever arising out of any policy of insurance insuring the patient or any other party liable to the patient, such benefits are hereby assigned to Home Towne Beauty for application to patient?s bill. The patient maybe responsible for 100% of charges not covered by this assignment. Home Towne Beauty will not bill or collect from medical insurance directly. Any charges not covered by insurance or any supplementary insurance may be the responsibility of the patient.
My initials acknowledge the opportunity to review the ?Notice of Privacy Practices?.
My initials acknowledge the opportunity to review the ?Patient Rights & Responsibility? notice.
THE UNDERSIGNED CERTIFIES: That he/she has read the foregoing, and is the patient, or is duly authorized by the patient as his/her legal representative to execute the about and accept its terms. If competent, the patient should sign in space indicated. If a minor, or incapable of signing, responsible representative should sign in the space indicated
CLIENTS WHO ARE MINORS: Please note that Botox, Juvederm and Kybella are not approved for anyone under the age of 21. This authorization would only pertain to services deem medically appropriate for the clients? age.