Conditions of Treatment

CONDITIONS OF TREATMENT

Consent to Medical and Surgical Procedures:

I consent to procedures that may be performed on an outpatient basis, including medical treatment or services, which may include but are not limited to laboratory procedures, X-ray examinations, medical or surgical treatment or procedures.

I understand that I will be asked to consent in writing for specific treatment and procedures as required after I have been given information about risks, benefits, and alternatives and have had any questions answered. Beauty Refined Plastic Surgery may participate in programs to teach resident doctors, medical students, student nurses and other health care students. These persons may observe or participate in the Patient's care under the supervision of doctors, nurses and other professionals employed by the clinic.

Consent to Photograph/Videotaping:

I consent to the taking of photographs, digital or other images of my medical condition or treatment, and the use of the images, for purposes of my diagnosis or treatment, including peer review and education or training programs conducted by other health care organizations.

Prop 65:

California's Safe Drinking Water and Toxic Enforcement Act commonly known as Proposition 85 which makes it unlawful for any person in the course of business to expose any individual in California to a chemical that is ligated by the State as a carcinogen or reproductive toxicant without first providing a clear and reasonable warning, even then the exposure is only in trace amounts. The list of products that contain chemical(s) known by the State of California to cause birth defects or other reproductive harm can be found at https://oshha.ca.gov/proposition-65.K. It is possible that, given the nature of medical services including but not limited to the use of chemicals, pharmaceutical products and equipment that emits radiation, when providing medical services to patients, that one, or more products may be used during your treatment or while at one of our facilities, you may be exposed to one of these products.

Assignment of Benefits and Payment Guarantee

I assign to Beauty Refined Plastic Surgery and / or Dr Tantawi the right to bill and collect from any insurance l have and I agree to cooperate in seeking payment. I will pay any deductible or co-payment and any amounts denied or not covered by Insurance. Estimates of deductibles and co-payments are subject to change. It is understood that it is my responsibility to obtain any authorization required by my Insurer or health plan for services or specific tests or treatments and to give that authorization to us. I understand that if my Insurer does not authorize any services, and I decide to receive them, I will be responsible for payment. Beauty Refined Plastic Surgery maintains a list of Insurance Companies with which it contracts. A list of such plans is available upon request. I understand that if Beauty Refined Plastic Surgery and / or Dr Tantawi is not in my health plan's network or is not a preferred provider, or I do not have a referral or authorization or if agreed not to submit a claim to my insurance plan at my request, I may have to pay more, or I may have to pay the full charge.

Release of Information:

Beauty Refined Plastic Surgery and / or Dr Tantawi will obtain the patient's consent and authorization to release medical Information, other than basic information, concerning the Patient, except in those circumstances when permitted or required by law to release information. The undersigned has consented to the release of Information to entities that provide care in post-acute settings. Beauty Refined Plastic Surgery and/ or Dr Tantawi is authorized, without further action by or on behalf of the Patient or any entity affiliated with Patients for all or part of physician's charges for the Patient's services (including, without limitation, medical service companies, Insurance companies, workers' compensation carriers, welfare funds, Patient's employer, or medical utilization review organizations designated by the foregoing).

We May Call or Send Text Messages to Your Phone Number(s)Provided and Send Email Communication to Your Email Addresses Provided You acknowledge that you are the owner of the phone numbers (whether associated with a mobile, cell or land line and email addresses that you provide to us. If you are not the owner, you represent that you are authorized by the respective owner(s) to authorize the use of those phone numbers and email addresses as described below, on the owner's behalf. You authorize us and any third-party, such as our independent contractors, business associates, agents, and/or affiliates, who we may authorize, to: (1) call you at any of the numbers that you provide to us, using an automatic telephone dialing system and/or using a recorded message upon being answered, or another similar method such As an artificial or pre-recorded voice; (2) text messages to you at any of the numbers that you provide to us; and/or (3) send email communications to you at any of the email addresses that you provide to us; for any of the following purposes: confirming appointments, providing registration or clinical Instructions, communicating about post-service follow up, telemarketing, billing, advertisements, advising you of special offers, events and services, communicating about your account, insurance and payments, and collecting debts that you owe to: us. You do not have to give us permission to call, text or email you. Giving us permission to call, text or email you Is not required in order to receive services or purchase any property or goods. You have the right to opt out of these types of communications.

Please initial below

Notice to Consumer: Medical doctors are licensed and regulated by the Medical Board of California Patients may obtain Information or complain about a California medical doctor at: 800-833-2322 or http://www.mbc.ca.gov.

Cancellation and Late Arrival Policy:

I understand that I will be responsible for arriving for scheduled appointments on time and to provide 24-hour notice of cancellation of any appointments. If I fail to give proper notification of cancellation of visit a total of three (3) times within a twelve (12) month period, this may result in dismissal from the practice

Please initial below:

The Undersigned acknowledges receipt of the following: 1) Patient Rights and Responsibilities 2) Notice of Privacy Practices (NPP) 3) Financial Assistance Pamphlet and Application Packages (If applicable)

Agreement: The undersigned certifies that he/she has read the foregoing, received a copy thereof, and is the Patient, the Patients legal representative, or is duly authorized by the Patient as the Patient's general agent to execute the above and accept its terms.

Date

Time (HH:MM AM/PM)

Patient/Parent/Guardian/Responsible Party

Electronic Signature

A COPY OF THIS DOCUMENT IS TO BE GIVEN TO THE PATIENT AND ANY OTHER PERSON WHO SIGNS THIS DOCUMENT.

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conditions of treatment

CONDITIONS OF TREATMENT

A COPY OF THIS DOCUMENT IS TO BE GIVEN TO THE PATIENT AND ANY OTHER PERSON WHO SIGNS THIS DOCUMENT.

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