Patient Financial and Treatment Terms — v1

Financial responsibility

Payment

This is a self-pay account. Payment in full is due at the end of each service unless the office or business manager approves another arrangement in writing. Verbal payment arrangements are not binding.

I am responsible for charges for services provided to me or my dependent. If treatment stops, any unpaid charges for services already provided are immediately due.

Cancellation and late arrival

Please provide at least 48 hours’ notice to cancel or reschedule an appointment.

Late cancellations and reschedules are charged 50% of the scheduled appointment’s service price. For my first late cancellation or reschedule, the full fee becomes an account credit. This exception is available once per patient, whether the first late change is a cancellation or a reschedule. Later late changes are charged the same fee without credit.

This account credit does not expire and has no restrictions on use for services. It cannot be exchanged or refunded for cash.

No-shows are charged 50% of the scheduled appointment’s service price, with no credit—even for the first no-show.

Corinne may reschedule my appointment if I arrive more than 15 minutes late.

Care communications and information sharing

Corinne Aesthetics PC uses patient information for care, appointments, payments and practice operations. Information may be shared with the support companies below, subject to applicable privacy requirements. The patient privacy notice explains other disclosures permitted or required by law.

Corinne Aesthetics LLC handles marketing, sales, administration and bookkeeping for Corinne Aesthetics PC. SalesMD handles sales outreach and bookings and can also access treatment details or medical records. Access must be appropriate for the purpose and comply with applicable law and safeguards. These descriptions do not authorize medical-information marketing or either company’s own unrelated marketing. Any required authorization must be obtained separately.

I authorize care-related communications, appointment reminders, requests for information, and payment verification by telephone, voicemail, mail, email or text. Please tell us your preferred contact method and any restrictions on leaving messages. Email and text may carry privacy risks; contact us to request an alternative method.

Promotional messages and Google advertising measurement are separate optional choices. Agreeing to care communications, signing the general intake or receiving the privacy notice does not authorize either.

To change communication preferences, withdraw an optional authorization, or ask about privacy, contact [email protected]. Withdrawal applies to future disclosures and does not undo disclosures already made in reliance on a valid authorization.

Treatment consent

Please read these terms and ask any questions before signing. You may request a copy.

I request evaluation and treatment by Corinne Aesthetics PC and rely on the treating provider’s professional judgment. I will report sensitive areas, symptoms or adverse reactions before, during and after treatment. I may ask questions about the procedure, treatment area, side effects and complications throughout my care.

Fees pay for services, not a guaranteed outcome. Results cannot be guaranteed, even when a good outcome is expected and realistic expectations have been discussed.

In a medical emergency during treatment, I consent to transport by practice staff or emergency medical services to a hospital or emergency facility.

Patient release — original wording for review

I, the undersigned, hereby attest and represent that I have disclosed all pertinent information regarding my health profile to Corinne Aesthetics PC and to the provider of service during my pre-treatment examination.

I further represent and guarantee that I have disclosed all medications that I am currently taking to Practice and to this provider of service during my pre-treatment examination and from whom, if any, I am obtaining my medications.

I understand that Practice and this provider of services make a determination based on the full disclosure I give of all medical conditions and history, past and current. Should information be obtained that in any way suggests false representation was made to Practice or the provider of services by the patient (me), I, without reservation, waive any and all rights to any claim of any type or nature whatsoever against the provider of service and this clinic, including but not limited to monetary damages, which I have now or in the future may accrue.

I understand that if I lose my medications, which are dispensed on a bi-weekly or monthly basis, I will not be able to obtain a new supply until the following office visit, whether it be bi-weekly or monthly.

As a patient, I also understand that if I go to another clinic or provider of service during the time frame of treatment at this Practice, I am to notify Practice and its representatives immediately and in writing of any other medications I might be receiving. Such written notification must be made between this clinic and/or its representative and myself. As the patient, I will also receive a copy of this notification after it is awarded.

As a patient, I have read and understand this release. I also understand that this release constitutes a legal and binding document.

Refund policy

Services and package credit

The provider will discuss treatment options, goals, expected results, benefits and risks. Purchased services are nonrefundable.

Unused package value may be applied to another service if the provider determines I am clinically eligible. Package credit is not transferable.

Skin-care products

Skin-care product sales are final. If a product causes a reaction, it may be returned within seven days of purchase for a full refund.

Completed injectable treatments

All injectable treatment sales (including but not limited to: Botox, Xeomin, Juvederm, Radiesse, Restylane, Perlane, and Sculptra) are final; refunds or credits cannot be offered once treatment is completed.

Ongoing intake, health updates and good faith examination

This intake acknowledgment remains on file for ongoing care. Updated information or a new acknowledgment may be required if circumstances change. I may withdraw consent before future treatment. Withdrawal does not undo completed care, charges already incurred or legally required record retention. Optional authorizations have their own terms and withdrawal procedures.

I must promptly tell the treating provider about changes to my health history, medical conditions, medications, supplements, allergies, pregnancy status or previous treatment reactions, including changes since my last visit, and before receiving further treatment.

Corinne requires a new good faith examination every 12 months. The clinician may require an earlier exam if my health changes, I request a new treatment or other clinical circumstances require it. An exam does not guarantee eligibility for every treatment.

This general intake is not blanket consent to all future procedures. Before treatment, the provider must obtain appropriate informed consent for the proposed procedure, including its risks, expected benefits and alternatives. I may ask questions and decline or withdraw consent before treatment.