CONSENT FOR TREATMENT. I consent to all diagnostic and treatment procedures/examinations provided at all offices of Georgia Dermatology Partners. This will include, but not limited to injections, biopsies, administration of medications, treatments, and procedures considered medically necessary for the care of my dermatologic condition.

I understand that the procedures will be explained to me and that I will have the opportunity to ask questions concerning the associated risks, alternatives and prognosis before allowing the procedures to be performed.

I consent to treatment and care provided by a team of healthcare providers, which may include dermatologists, mid-level providers such as physician assistants or advanced care practice nurse practitioners.

CONSENT FOR DISPOSAL OF HUMAN TISSUE.  I agree that any tissues or specimens that are removed from my body in the course of performing my Procedures or providing my care and treatment will be examined and disposed of by Georgia Dermatology Partners.

TELEPHONE CONSUMER PROTECTION ACT CONSENT.  I expressly consent to receive telephone calls and text messages from Georgia Dermatology Partners, its affiliates, agents, vendors or third parties calling or texting on its or their behalf at any number that I provide or that they may obtain for me.  Such calls or texts may be made using an automatic telephone dialing system and/or prerecorded or artificial voice and may be made for any non-marketing purpose.  , including but not limited to:  communications about my treatment, medication assistance, insurance benefits or account; appointment reminders; balance due and payment reminders; and debt collection attempts. 

MEDICATION CONSENT.   I provide consent to access and obtain a history of my medications purchased at pharmacies. 

PHOTOGRAPHS, VIDEOTAPES, AND RECORDINGS: I agree to turn off all recording devices prior to entering the exam room. I understand that physicians and Georgia Dermatology Partners staff may request to take photographs, videotapes, or other recordings of me for purposes of ensuring proper patient identification or for medical documentation, care, or treatment purposes.  I understand the photograph(s) or videotape(s), will be used for documentation of my medical condition.   For example, my clinical team will take pictures of my skin condition, biopsy site, or surgical site.  They will also take before and after pictures to monitor the progression of my condition.   I consent to being photographed, videotaped, or recorded for these purposes.  I further acknowledge that such photographs, videotapes, recordings and related information may be used for internal operations including, but not limited to quality improvement activities and training programs that do not include treatment. 

ASSIGNMENT OF BENEFITS.   If I am entitled to benefits under the Medicare program or any insurance policy or other health benefit plan, in consideration for services provided to me by Gwinnett Dermatology, dba as Georgia Dermatology Partners, I assign, transfer and convey the benefits payable under such program, policy, or plan for services rendered to Georgia Dermatology Partners.  I authorize payment of benefits directly to Gwinnett Dermatology dba Georgia Dermatology Partners, with such benefits applied to my bill. 

PATIENT RESPONSIBILITY. I understand and acknowledge that the assignment of benefits does not relieve me of my financial responsibility for charges incurred by me or anyone on my behalf, and I hereby acknowledge responsibility for and agree to pay charges not paid under this assignment, including any coinsurance amounts and deductibles and any charges for services deemed to be non-covered,  or not preauthorized by my insurance plan.  I agree to provide all known insurance information at the time that services are rendered.  In the event that I overpay on my account, I authorize the application of such overpayment to satisfy any outstanding charges I owe for services rendered by any facility of Georgia Dermatology Partners.      

INFORMATION RELEASE. I authorize Georgia Dermatology Partners to release all protected health information to my insurance,  (including Medicare, if appropriate) and third-party collection agencies in order to secure payment for services rendered.  I also authorize Georgia Dermatology Partners to release my medical information to my Primary Care Provider or Referring Provider for continuity of my care. 

REFERRALS.  I understand that it is my responsibility to obtain any referrals required by my insurance company from my primary care physician or insurance carrier.  It is my responsibility to make sure that my referral is accurate and denial of payment because of my failure to do this will result in my being personally responsible for the charges incurred.

CANCELLATION POLICY. We will reserve your appointment time specifically for you. We do understand that an emergency or unforeseen event may result in the need to cancel at the last minute. However, we respectfully request that you give us notice if you need to cancel or reschedule. Medical appointments missed with no notice or cancelled with less than one (1) business day notice will be assessed a $35.00 no show/late cancellation fee. We charge a $100 fee for each surgical procedure or cosmetic procedure missed or cancelled with less than three (3) business days’ notice. Appointments cancelled during non-business hours, such as on Saturday or Sunday, will be assessed a late cancellation fee for appointments scheduled on Monday. Patients who miss or cancel without notice on more than two (2) occasions will be required to pay a $100 deposit when scheduling future appointments.

DEPOSIT POLICY.  I understand that a $100 non-refundable deposit may be required when scheduling first appointments for fillers.  Appointments for Fraxel and Bellafill require a $500 non-refundable deposit at the time of scheduling.  Appointments scheduled for Coolsculpting and Ultherapy must be paid in full at the time of scheduling.  Patients who miss or cancel without notice on more than two occasions will be required to pay a deposit when scheduling all appointments.   

RETURN POLICY.   I understand that we cannot accept returns of skin care products and prescription pharmaceutical preparations.   These products are non-refundable.

TREATMENT GUARANTEE.  Although good results are anticipated, I understand that there can be no guarantee or warranty, expressed or implied, by anyone as to the actual results I may get. 

The results of certain procedures may not last as long as expected or meet the degree of your expected improvement. It is important that you understand that all services are non-refundable.

Surgical revisions and/or other medical treatment or management of problems and/or complications may be required. These will result in additional charges for which you will be responsible.

 

We value our relationship with you and we consider it a privilege that you have chosen us for your dermatologic, surgical or cosmetic needs.  We want to assure its ongoing success through a mutual understanding of our cancellation policies.  

 
Cosmetic Consultations

Consultations for non-surgical facial rejuvenation, all aesthetic services, including skin care, are provided for a fee of $50.00. If aesthetic services are rendered within 30 days of the consultation, this fee will be applied to the services rendered. Please note there will be a $35 fee charged to your account if you are a No Show to your appointment or cancellation of your appointment is made with less than a 24-hour notice. This fee will not be billable to your insurance and must be paid prior to scheduling another consultation.

Surgery and Cosmetic Procedures

We understand that a situation may arise that could force you to cancel or postpone your surgery. Please understand that such changes affect not only your surgeon, but other patients as well.  Gwinnett Dermatology will reschedule a surgery/procedure one time at no charge when notice is provided 24 hours prior to the procedure.  Beyond that, there will be a $100 charge each time a surgery/procedure is rescheduled.  This fee will not be applied toward your surgery/procedure and will be added as a charge to your account.  This will not be billable to your insurance. 

Fees for in-office treatments such as dermal fillers, neurotoxins (such as Botox®, Dysport®), chemical peels, laser hair removal, vascular lasers, laser resurfacing and other similar procedures are priced either on a per treatment basis or as a treatment package, and are payable in full at the time of your appointment. Treatments and series of treatments are non-refundable.

If any touch ups are needed there will be a modest fee for set-up, sedation, materials and medications used. The procedure itself is performed without doctor’s charges. In case of Botox we always apply a determined number of units per area that in some patients might not be enough. In the event that extra doses of neurotoxins (Botox, Dyport, etc.) are needed, a charge per extra units will be assessed.

Treatment of Complications

The practice of medicine and surgery is not an exact science. Although good results are anticipated, there can be no guarantee or warranty, expressed or implied, by anyone as to the actual results that you may get. The results of certain procedures may not last as long as expected or meet the degree of your expected improvement. It is important that you understand that all services are non-refundable.

Surgical revisions and/or other medical treatment or management of problems and/or complications may be required. These will result in additional charges for which you will be responsible.