Patient Information
Name: _________________________
Date of Birth: __________________
Chart Number: __________________
Agreement Terms
1. Appointment Policy
- I understand that I must provide 24-hour notice for appointment cancellations
- Three missed appointments without proper notification may result in dismissal from the practice
- Late arrivals (>15 minutes) may require rescheduling
2. Financial Responsibility
- I agree to pay all copayments at the time of service
- I understand I am responsible for any charges not covered by insurance
- Cosmetic procedures require payment in full prior to treatment
3. Photography Consent
- I authorize clinical photography for medical documentation
- Images may be used for:
- Medical records
- Treatment planning
- Educational purposes (with separate written consent)
4. Treatment Compliance
- I agree to follow prescribed treatment plans
- I will report any adverse reactions promptly
- I understand that certain treatments require consistent follow-up
5. Communication
- I consent to receive appointment reminders via:
- I will inform the practice of contact information changes
6. Prescription Policy
- Medication refills require 48-hour notice
- Some medications require periodic in-office evaluation
- I agree to use only one pharmacy for prescribed medications
Signatures
Patient/Guardian: _________________ Date: _______
Provider: _______________________ Date: _______