DERMATOLOGY CENTER
The undersigned patient (or undersigned person financially responsible for the
hereafter designated patient) understands and agrees that his or her health plan
may determine that the medical services rendered are not “medically necessary”
within the provision of such health plan or are not covered by such plan. In the
event of such determination, the undersigned patient (or undersigned person
financially responsible for the hereafter designated patient) agrees to pay for such
services.
____________
Date
______________________________________________
Patient
____________
Date
______________________________________________
Person financially responsible for patient
____________
Date
_______________________________________________
Witness00
Some procedures that are often not covered by most insurance include:
__ Botox Injection
__ Salac Peel
__ Cyst
__ Juvederm
__ 50/50 Peel
__ Milia
__ Restylane
__ TCA Peel
__ Scar Injections
__ Sclerotherapy
__ Glycolic Peel
__ Keloid Romoval
__ Hair Laser
__ Skin Tags
__Warts
__ Vascular Laser
__ Seborrheic
Keratosis
__ Permanent
Cosmetics
Would you be interested in any of these above services? ___ Yes ___ No
If yes, please check the ones you would like to know more about.