I hereby certify that the above information is true and accurate and there have not been any omissions from my medical history.
I understand there is a 48-hour (2 business day) cancellation policy to allow us ample time to offer your appointment to another patient. A fee may be charged for missed appointments or failure to reschedule before the 48 hour time limit.
I understand that Drs. Mark and Matt Friedman are not providers for any medical or dental insurance plans and are not Medicare providers. I understand that I will be financially responsible for all charges incurred and I agree to make payment for professional services at the time they are rendered. I consent to the taking of clinical photographs for the purpose of treatment and/or educational use. I authorize the release of any information to my insurance companies or specialists to whom I am referred. Should it be necessary to take any action against any of the parties to this agreement to enforce the provisions thereof or to take any action which is related to or arises out of this agreement, Drs. Mark and Matt Friedman shall be entitled to all costs and expenses including but not limited to, attorneys’ fees, service charges and collection agencies fees incurred therein but not to exceed $5,000. Accounts extending over thirty days will be charged 0.833% interest per month.
By my electronic signature below, I agree to the terms and conditions.