Consent Forms, Office Policies, & More

Consent Forms

Important Safety Information

Botox 1 & 2

Juvéderm

Latisse

Kybella

Radiesse & Belotero Balance

Asclera

Quick Note

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.

Payment Information

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.
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A copy of this waiver is available in print or electronically. Please ask a staff member. Thank you!

I voluntarily authorize the rendering of services by 5 Star Medical Inc. providers and employees. I acknowledge that no guarantees are made as to the effect of such examination, recommendation, or treatment on my condition or the condition of the person for whom I am duly authorized to make decisions. I acknowledge the right to refuse medical and surgical procedures. I understand all services are elective and non refundable. All services must be paid in advance or on day of service. Services provided are not billed to medical insurance. Please call 5 Star Medical Inc. for questions. Staff of 5 Star Medical Inc. may not be available at all times. Please leave a message, email, or text. All emergencies should be directed to the nearest emergency room or specialty practice. Emergency treatment for complications should be reported to 5 Star Medical Inc. but please do not delay evaluation or treatment if intervention is necessary. Any complications must be treated at patient expense.

By law, 5 Star Medical Inc. is required to provide you with our Notice of Privacy Practices. This notice describes how your medical records may be used and disclosed by our staff. It also tells how you may obtain access to this information. 5 Star Medical Inc. wants to insure you that your medical and protected health information is secured. As a patient, you are entitled to the following rights:
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.

Cancellations without 24 hour notice will result in a fee. Late appointment arrivals of more than 10 minutes or more may require the appointment to be rescheduled to assure your safety and best results for treatment. To avoid an automatic charge to your account or credit card on file, please cancel or reschedule at least 24 hours before your appointment either by phone, email, or online scheduling. We send a 48 hour auto email reminder for your appointment followed by a text message at least one business day prior. Please understand that when you don’t show for your appointment, staff still must be paid.
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.

I consent to photographs and/or video being taken to record baseline state, evaluate treatment result, for medical education, training, professional publications and/or sales purposes. No photographs revealing my identity will be used without my written consent. If my identity is not revealed, these photographs may be used and displayed publicly without my permission.

Please contact us with any questions or concerns you may have. We look forward to speaking with you soon!

For Disclosures & the Important Safety Information Affiliated with the products we use in our practice please click here.