Consent Forms, Office Policies, & More
On the left you will find the disclosures for all heath and safety information that is affiliated with some of the products we use in our practice. Please take a moment to view the important health and safety information.
These are just a few of the products we offer and of course we will go over all of the products we offer and find the best solution for you! Our website is meant to operate as an informational hub but all information and content here is strickly for informational purposes only and is not intended to replace the advice of any other medical professional.
I understand that these procedure are cosmetic and that payment is my responsibility. I further agree, in the event of non-payment, to bear the cost of collection, and/or court costs and reasonable legal fees, should they be required. Should additional procedures be necessary payment for materials and labor is expected at time of service. There are no free touch ups or refunds for treatments rendered. Outside consultants or procedures stemming from these procedures are not the responsibility of 5 Star Medical Inc. or providers. I understand and agree that all services rendered will be charged directly to me, and I am personally responsible for payment. I further agree, in the event of non-payment, to bear the cost of collection, and/or court costs and reasonable legal fees, should they be required.
Consent Form Summary
I hereby voluntarily consent to treatments offered at 5 Star Medical Inc. including but not limited to Laser and Light based treatment, Relaxing Facial Muscles, Fill Beautiful, Chemical Peel, and other medical treatments. The opportunity to discuss procedures has been offered to me. I will ask questions prior to participation in these procedures. I have read the above and understand it. I accept the risks and complications of the procedure.
I understand that if any changes occur in my medical condition, medications, or health I will report it to the office as soon as possible.
A copy of this waiver is available in print or electronically. Please ask a staff member. Thank you!
The right to inspect and copy your information.
The right to request corrections to your information.
The right to request that your information be restricted.
The right to request confidential communications
The right to a report of disclosures of your information
The right to a paper copy of this Notice
I hereby acknowledge and understand that I have received a copy of this practice’s NOTICE OF PRIVACY PRACTICES. I understand that if in any case I have questions or concerns regarding my privacy practice rights, I may contact the 5 Star Medical Inc. I further understand that the practice will make available to me updates to this NOTICE OF PRIVACY PRACTICES if in any case, should it be changed, amended, or modified in any way.
Fee $25 for 1st missed/no show appointment or cancellation less than 24 hours. Fee $69 for 2nd and each subsequent appointment.
Signature of this liability waiver indicates acknowledgement of the above and responsibility for payment of all services rendered on the signer’s behalf and of signer’s dependents.