William W. Lao M.D., Plastic Surgery

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Assignment and release

I,

, assign directly to Dr. William W. Lao, and associates all medical benefits, if any, otherwise payable to me for service rendered. I understand that I am financially responsible for all charge incurred. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions.

Refund policy: Please note that our office does not provide refunds on any services rendered. All sales, including deposits for treatments, are final. Skincare products may be exchanged if damaged or unused within 14 days of purchase.

I acknowledge that I am required to be photographed for my medical record

before and afer my procedure at William W. Lao M.D. (Required)

I allow these images to be used for plastic surgery education, marketing purpose

and social media by William W. Lao, M.D ‘s team without revealing my idendity. (Optional)

Acknowledgement

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosure received. I certify that the preceding medical, personal, and skin history statements are true ad correct. I am aware that it is my responsibility to inform the doctor of my current medical or health conditions and to update this history per appointment. I understand that withholding information or providing misinformation may result in contraindications and/or reactions to the skin from treatment(s). The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.