Cancellation/No-Show Policy: It is the patient’s responsibility to contact the office at least 48 hours in advance to cancel regularly scheduled visits. If the patient fails to notify the office or fails to appear 2 or more times, the patient may be assessed a fee of $50 for regularly scheduled visits. There will be a $100 fee for any surgery or patch testing appointments that are not canceled within 48 hours or if the patient fails to appear. Repeated late cancellations or no-shows may result in dismissal from the practice.
MediSpa Cancellation/No Show Policy: Our Medispa policy requires a consultation fee to be paid at the time of scheduling. If you need to cancel your procedure with less than 48 hours' notice, or if you do not show for your appointment, a fee will apply. This fee must be paid before any future cosmetic appointments can be scheduled.
For cosmetic procedures with a physician, a 50% deposit is required at the time of booking. If the appointment is cancelled with less than 48 hours' notice or you fail to show for your appointment, the deposit will be forfeited.
MediSpa procedures that are non-injectables must be paid in full at time of scheduling.
Some procedures may require a credit card on file. A separate form will be provided
Consent to Treatment & Financial Acknowledgement: I consent to the necessary diagnostic exams and procedures performed by my medical provider and their staff. I understand that photographs may be taken during treatment for medical documentation and to support my care.
I acknowledge that while complications are rare, even minor procedures can result in scarring, bleeding, infection, or allergic reactions. The staff is committed to providing the highest quality care possible.
I authorize the release of medical information to other healthcare providers, pharmacies, consultants, and insurance companies as needed for treatment and claims processing. For surgical procedures or biopsies, I understand there may be separate charges: one for the procedure and another for the pathology review, which may be billed separately if sent to an outside lab.
DCSI may file insurance claims on my behalf and will receive payments directly from my insurance. I authorize DCSI to appeal claim denials and release any necessary medical information to my insurance carrier. It is my responsibility to ensure DCSI is in-network, confirm my benefits, provide updates to my insurance, and obtain any necessary referrals.
Copays are due at the time of service. If Coordination of Benefits (COB) is unresolved, I am responsible for any outstanding balance. Accounts unpaid 60 days after insurance response may be sent to collections, and I will be liable for all associated fees.
If uninsured, a $160 deposit is due at the time of service unless other arrangements have been made. I will be billed or refunded based on the final charges. Returned checks are subject to a $25 fee, and future balances must be paid by cash or credit card.
Communication Notice: Please note that our office may contact you via text message, email, or phone call. These communications may be sent directly from our office or through a secure, trusted third-party vendor acting on our behalf, and may contain protected health information (PHI).
