Please initial to provide consent or acknowledgement.

CONSENT FOR TREATMENT. I consent to all diagnostic and treatment procedures/examinations provided at all offices of Georgia Dermatology Partners. This will include, but not limited to injections, biopsies, administration of medications, treatments, and procedures considered medically necessary for the care of my dermatologic condition.

I understand that the procedures will be explained to me and that I will have the opportunity to ask questions concerning the associated risks, alternatives, and prognosis before allowing the procedures to be performed.

I consent to treatment and care provided by a team of healthcare providers, which may include dermatologists, mid-level providers such as physician assistants or advanced care practice nurse practitioners.

MEDICATION CONSENT. I consent for Georgia Dermatology Partners to access and obtain a history of my medications purchased at pharmacies.

PHOTOGRAPHY CONSENT. I hereby authorize Georgia Dermatology Partners to photograph me or my dependent while I (he/she) am (is) a patient. I understand the photograph(s) or videotape(s), will be used for documentation of my (his/her) medical condition. For example, my clinical team will take pictures of my skin condition, biopsy site, or surgical site. My team will also take before and after pictures to monitor the progression of my condition.

NOTICE OF PRIVACY PRACTICES. I acknowledge that I have been provided a copy of the Notice of Privacy Practices from Georgia Dermatology Partners / Gwinnett Clinical Research Center for me to keep and that I have read (or had the opportunity to read if I so chose) the Notice.

RELATIONSHIP TO RESPONSIBLE PARTY

Please read and sign at bottom.

PATIENT RESPONSIBILITY. I understand that I am financially responsible for all services rendered. I understand that my insurance coverage is a contract between myself and my insurance company. Therefore, I am financially responsible for any unpaid balance not covered by my insurance. All copays, deductibles, and coinsurances not covered by my insurance carrier are my responsibility and will be due at the time of service.

PAYMENT ASSIGNMENT. I authorize and assign directly to Georgia Dermatology Partners all insurance benefits, if any, payable for any services rendered otherwise payable to me. I understand that this office will prepare all necessary claim forms to assist me in making collection from the insurance company.

INFORMATION RELEASE. I authorize Georgia Dermatology Partners to release all protected health information to my insurance carrier(s) (including Medicare, if appropriate) and third-party collection agencies in order to secure payment for services rendered. I also authorize Georgia Dermatology Partners to release my medical information to my Primary Care Provider or Referring Provider for continuity of my care.

REFERRALS. I understand that it is my responsibility to obtain any referrals required by my insurance company from my primary care physician or insurance carrier. It is my responsibility to make sure that my referral is accurate and denial of payment because of my failure to do this will result in my being personally responsible for the charges incurred.

CANCELLATION POLICY. We will reserve your appointment time specifically for you. Therefore, we respectfully request that you give us a minimum of 24-hour notice if you need to cancel or reschedule. We do understand that an emergency or unforeseen event may result in you needing to cancel your appointment at the last minute. However, appointments missed or cancelled without notice will be assessed a no show/late cancellation fee. We charge $25 for each medical appointment and $100 for each surgical or cosmetic procedure if the appointment is missed or the appointment is cancelled with less than 24-hour notice.

DEPOSIT POLICY. I understand that a $100 non-refundable deposit may be required when scheduling first appointments for fillers. Appointments for Fraxel and Bellafill require a $500 non-refundable deposit at the time of scheduling. Appointments scheduled for Coolsculpting and Ultherapy must be paid in full at the time of scheduling. Patients who miss or cancel without notice on more than two occasions will be required to pay a deposit when scheduling all appointments. PHOTOGRAPHY POLICY. I agree to turn off all recording devices prior to entering the exam room.

RETURN POLICY. I understand that we cannot accept returns of skin care products and prescription pharmaceutical preparations. These products are non-refundable.

TREATMENT GUARANTEE. Although good results are anticipated, I understand that there can be no guarantee or warranty, expressed or implied, by anyone as to the actual results I may get. I also understand that additional charges, in which I will be responsible, will be applied for the management of problems and/or complications.