Governors MedSpa - Patient Form

Patient Credit Card on File $ Free

Payment Plan Agreement

I have read the Payment Plan Agreement. I understand and accept all of the terms in full by signing below.
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REFERRAL INFORMATION
How did you hear about us?

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PRIVACY PRACTICES & DISCLOSURE
Receipt of Notice of Privacy Practices

Our notice of Privacy Practices provides information about how we may use and disclose protected health information about you. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy by mail or in person at our office.

By signing below, you acknowledge that you have read, received or declined a copy of our Notice of Privacy Practices on the date indicated below.
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Disclosure of Private Medical Information

I authorize Governors MedSpa and Concierge Medicine to disclose medical information pertaining to my personal health to the following persons:

Missed Appointment Policy

If you are unable to keep an appointment, please let us know no less than 24 hours in advance. Please be advised that if you are not a Governors Plan Member, your account will be charged a $50 missed appointment fee for office or aesthetician visits and a $150 missed appointment fee for physical examinations, if 24-hour cancellation is not given.
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