Thank you for completing our Body Contouring Intake Assessment. Your responses will help guide your discussion with a qualified medical professional to determine the most appropriate procedures for your individual needs and goals.
I, the undersigned patient, hereby acknowledge and agree to the following terms and conditions associated with receiving services at Rapaport Plastic Surgery [David P. Rapaport, MD, FACS], hereinafter referred to as the "Practice."
Privacy and Confidentiality
Medical Records: I understand that the Practice will maintain my medical records in accordance with applicable privacy laws and regulations. My medical records may be shared with other healthcare providers involved in my care as needed and as required by law.
Medical Documentation: I understand that photographs and/or video recordings may be taken before, during, and after medical procedures for the purpose of medical documentation, tracking progress, and evaluating treatment outcomes. These images may become a part of my medical record.
Use of Information: I authorize the Practice to use my personal and medical information for treatment, payment, and healthcare operations, including but not limited to, appointment reminders, billing, and quality improvement activities.
Third-Party Disclosures: The Practice may disclose my information to third parties for purposes such as insurance claims, legal requirements, or when necessary for my treatment. The Practice will take reasonable measures to protect my information.
Marketing Communications: I understand that I may receive marketing communications from the Practice via email or other means. I have the option to opt out of these communications at any time.
Financial Responsibility
Payment Responsibility: I am responsible for all fees associated with the services provided by the Practice. Payment is due at the time services are rendered unless other financial arrangements have been made in advance.
Insurance: If applicable, I understand that it is my responsibility to provide accurate insurance information, and I am responsible for any deductibles, co-payments, or services not covered by my insurance plan. I also understand that for pathology and bloodwork, any billing inquiries should be directed to the laboratory. Furthermore, I acknowledge that it is my own responsibility to seek reimbursement for treatments rendered at the Practice.
Cancellation/No-Show Policy: I understand that I must provide the "Practice" Rapaport Plastic Surgery [David P. Rapaport, MD, FACS], with at least 2 business days of notice for appointment cancellations or rescheduling. Missed, rescheduled, or cancelled consultations without 2 business days' notice will incur a fee of $250.00. Missed, rescheduled, or cancelled treatment(s) without 2 business days' notice will incur a fee of $250.00.
Financial Agreement: I acknowledge that I have received a written or verbal financial quote outlining the cost of the services I will receive. I agree to the terms and conditions specified in that quote. I understand that our office does not offer any refunds for deposits or services rendered.
Retail Item Exchanges: For retail items purchased from the Practice, I understand and agree to the following exchange policy: All retail item sales are final, and exchanges will only be issued for defective or damaged items. To request an exchange for a defective or damaged item, I must notify the Practice within 30 days of the purchase date. Exchanges will be issued for the same product stated in the original purchase receipt. In case of allergic reactions, refunds are due to office policy and must provide a doctor's note confirming clinical diagnosis.
HIPAA Compliance Acknowledgment: I, hereby acknowledge that I have been informed about the Health Insurance Portability and Accountability Act (HIPAA) and understand its implications regarding the privacy and security of my protected health information (PHI
Consent: I have read and understand this Patient Waiver, including the sections on privacy and financial responsibility. I agree to abide by the terms and conditions outlined herein. I have had the opportunity to ask questions, and any questions I had were answered to my satisfaction.
Scheduling Agreement
As a courtesy to our providers and patients, we require at least 2 business days' notice for cancelling or rescheduling appointments. For example, all Monday & Tuesday appointments must be confirmed or rescheduled by the previous Thursday or Friday, within business hours, respectively, to avoid any fees.
Missed, rescheduled, or cancelled complimentary consultations without 2 business days' notice will incur a fee of $150.00.
Missed, rescheduled, or cancelled treatment(s) without 2 business days' notice will incur a fee of $250.00.
All appointments require a credit card on file including complimentary appointments and services intended to be paid for with a gift card.
Some of our services require a scheduling deposit at the time of booking.
Scheduling deposits are applied towards your scheduled treatment. The scheduling deposit is nonrefundable.
Please note that we do not accept third party financing for appointment deposits. Payments for procedures are non- refundable.
Consultations with Dr. David P. Rapaport are $500.00, due 2 business days prior to the scheduled appointment. The consultation fee is non-refundable. Your consultation fee is applicable to your quote for up to one year from the date of issuance.
Dr. Mansher Singh offers complimentary consultations. However, please note that a valid credit card is required to schedule your appointment.
Missed, rescheduled, or cancelled consultations without 2 business days' notice will incur a fee of $250.00.
Credit card information is stored for securing your treatment pricing, appointment date/time, & for online purchases only. Please present your credit card at the time of service to pay for any balances on your account.
I authorize the Practice & any of its Associates/Providers to keep my credit card information on file and to charge this card for any outstanding balances. Credit card information is stored for securing your treatment pricing, appointment date/time, and for online purchases only. Please present your credit card at the time of service to pay for any balances on your account.
My signature below indicates I have read, understand, and agree to the terms stated in this agreement.