Follow-Up Appointment Acknowledgment & Fee Consent Form
  • Follow-Up Appointment Acknowledgment & Fee Consent Form

    Please review the information below and sign to acknowledge your understanding and agreement.
  • Weekly in-person follow-up visits are currently provided at no additional cost (subject to change) and are intended solely for injection assistance and routine monitoring of medication response. Visits for acute illness, new medical concerns, or general medical care are not included and may be billed separately.

    However, a formal follow-up is 3-month for all patients.
    This visit includes a comprehensive review of your progress, lab work, and overall care plan. A $75 fee applies to these appointments.

    By signing below, you acknowledge and agree to the following:

    *I understand that a 3-month formal follow-up is recommended as part of my ongoing care plan.
    *I agree to pay a $75 fee for each formal follow-up appointment, which may be scheduled at intervals of approximately 3 months or as clinically indicated.

    *I understand that this fee is not optional and applies to all patients.
    *I have had the opportunity to ask questions and understand this policy

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    Follow up  Product Image
    Follow up

    Recommended for all patients every 3 months. This appointment includes a comprehensive review of your progress, lab work, and care plan. Weekly follow-ups are free; this fee applies only to formal quarterly reviews.

    $75.00
      
    Total
    $0.00
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