Office Policies
Patient Clinic Policies & Acknowledgment
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Last Name
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Please review and check each box to acknowledge your understanding and agreement.
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Appointments: I understand that late cancellations, missed appointments, or late arrivals may be subject to a $50 fee in accordance with the clinic's cancellation policy.
Payment: Payment is due at the time services are provided.
Insurance: Bottumzup Health and Wellness is a cash-pay practice and does not bill health insurance. Upon request, an itemized receipt may be provided for me to submit to my insurance company. Reimbursement is not guaranteed.
Medical Emergencies: I understand that Bottumzup Health and Wellness is not an emergency medical service. For a medical emergency, I should call 911 or seek emergency medical care.
Changes in Health: I agree to notify my provider of significant changes in my health, medications, allergies, pregnancy status, or adverse reactions that may affect my treatment.
Treatment Eligibility: Scheduling an appointment does not guarantee that a requested medication, injection, IV infusion, procedure, or other treatment will be provided. Treatment is based on the provider's clinical assessment and medical judgment
Risks & Benefits: I understand that treatments may have risks, benefits, side effects, and alternatives. These will be discussed as appropriate for the service I receive, and I may ask questions before proceeding.
Refunds: I understand that completed services, administered treatments, medications, and products are non-refundable, except where otherwise required by law or clinic policy.
Preventive & Ongoing Care: I understand that I am responsible for obtaining recommended preventive screenings, routine follow-up, and specialty care as appropriate for my individual health needs.
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