By sharing how you see yourself. we can best evaluate your aesthetic goals and select on appropriate treatment for you.
I have answered the questions contained in the questionnaire to the best of my knowledge. I understand that it is my responsibility to inform my practitioner of my current health conditions while seeking treatments. I will update this information as it occurs or if there are any changes to my health in between treatments.
Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review or arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided on a court of law before king, and instead are accepting the use of arbitration.
Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or related to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether bron or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term "patient herein shall mean the mother and the mother's expected child or children.
All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician's partners, associates, association, corporation or partnership, and the employees, agents and estates of any if them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.
Article 3: Procedures and Applicable Law: A demand for arbitration must communicate in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party's pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party's own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, nit supplant, any other applicable statutory or common law.
Either party shall have the absolute right ti arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.
The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.
The parties agree that provisions of California law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to, Code of Civil Procedure Section 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrations a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure section 1283.05, however, depositions may be taken without prior approval of the neutral arbitrator.
Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in once proceeding. A claim shall be waived and forever barred if (I) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.
Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days, or signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition.
Article 6: Retroactive Effect If patient intends this agreement to cover services rendered before the date it is Effective as of the date of first medical services.
If any provision if this arbitration agreement is held invalid of unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.
I understand that I have the right to receive a copy of this arbitration agreement By my signature below, I acknowledge that I have received a copy.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING LT YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.
Gateway Medspa is a full-service aesthetic and nonsurgical clinical Dermatology establishment dedicated to giving you the best and most current treatments.
Our billing policy requires FULL PAYMENT due at time of service (including treatment packages).
All sales are FINAL on all products, services and treatment packages.
For your convenience, we accept cash or credit card as well as a payment plan option through Care Credit.
I fully understand and acknowledge Gateway Medspa's Billing Policy as stated above.
Our scheduling is designed to permit the proper amount of time to complete your service. A late arrival will deprive you of precious treatment time. In fairness to others, your treatment must end on time, so that the next patient's treatment can begin on time. If you are 15 minutes past your scheduled appointment, the appointment will need to be rescheduled.
In order to better serve you and maximize appointment availability, we require 24 hours advanced notice for cancellations/rescheduling. Any cancellations and appointment changes not made within 24 hours of the appointment, or a no-show will result in a $50 fee. A credit card number is required to schedule any appointment here at Gateway Medspa. If you schedule an appointment, it is assumed that you agree with our scheduling policy.
authorize Gateway Medspa and its employees to obtain images related to services rendered at Gateway Medspa. These photos will not be posted on social media or any websites unless patient has given consent.
to release any photos rendered by Gateway Medspa. These images may be used for social media and/or our Gateway Medspa website, however, names will not be released.
Although we love children, we do not offer child care services in our facility. Children under the age of 16 who are not receiving treatment are NOT PERMITTED in the med spa because we aspire to provide a very relaxing and peaceful environment for the enjoyment of our patients as well as for the safety of children, we must enforce this policy. If you are unable to arrange for childcare and need to bring your children with you, we will have to reschedule your appointment. We appreciate your understanding and apologize for any inconvenience.
Dr. Mendoza & Staff
I acknowledge that I have reviewed the Notice of Privacy Practices (NOPP); I was offered a copy of the NOPP for my file.
I have been informed that I have a right to request limitation of the use/disclosure of my protected health information for the purpose of treatment and/or payment of healthcare operations (HCO). While Gateway MedSpa is not required by law to grant my request, they have agreed that if they decide to grant my request, the will be bound by the agreement.
In consideration of the information given to me, I hereby consent to the use and disclosure of my protected health information (PHI) for the purpose of treatment, payment, and healthcare operation. This consent is good until revoked in writing, except to the extent that disclosure has been made in reliance upon my prior consent.
I give my consent for Gateway MedSpa to contact me by calling my home or other designated location in order to leave me a message (mechanically or in person) or to speak with me directly regarding any matter associated with my treatment, payment, or healthcare operation.
I give my consent for the use of mail or email to designated locations to assist Gateway MedSpa in carrying out the described activities of treatment, payment, and/or healthcare operations.
I understand that I have the right to revoke the consent in writing, except to the extent that Gateway MedSpa has already used or disclosed the subject information.
If signature of Patient Representative appears above, please describe the relationship of the Representative to the patient: