Cosmetic Demographic Form

Please correct the errors described below.

Patient Information

Referral Information

Financial Acknowledgement

By signing below, I authorize treatment and agree to the following terms: 1) Fifty percent (50%) of the total amount of treatment/service is due at the time of scheduling. 2) The remaining balance is due at the time of service. 3) I understand that twenty percent (20%) of the total amount of the treatment/service is non-refundable if I choose not to proceed with the treatment/service at any time during the scheduled appointment. 4) If I cancel the appointment without giving a minimum of three (3) business days' notice, I acknowledge that twenty percent (20%) of the downpayment is non-refundable.

Disclaimer

By signing below, I authorize cosmetic treatment/service from the Skin Cancer & Dermatology Center and their delegated medical professional and/or provider. I recognize that outcomes are not a guarantee and may vary. I understand that individual expectations for the desired effect are subjective, and I may be disappointed with the results. I acknowledge additional treatments/services may be necessary to achieve the preferred outcomes. You may receive promotionals information regarding product and service specials.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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