Cosmetic Procedure Consent

Please correct the errors described below.

I am agreeing to have a non-insurance-covered cosmetic procedure with a New Orleans Podiatry Associates-affiliated healthcare provider or physician. This procedure will not be filed with my insurance company, although the initial office visit allowing my evaluation and diagnosis will be filed with my insurance carrier unless otherwise notified. I hereby acknowledge my consent to accept treatment of the following procedure,

I also acknowledge and accept that there are no guarantees as to the result of the application administered today. I understand follow up visits for my condition are crucial to my treatment and will be billed to my insurance company or in the case of a self pay situation, will be placed to my responsibility.

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.

New Orleans Podiatry Associates

2626 Jena Street, New Orleans, LA 70115 - t. 504.897.3627 f. 504.897.3339
3939 Houma Blvd, Bldg. 5, Ste. 217, Metairie, LA 70006 - t. 504.457.2300 f. |

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