PAYMENT AND ASSIGNMENT

PAYMENT. I agree to pay any and all expenses incurred on my behalf or on behalf of the patient regardless of whether the patient is my family member), which are related to the medical care received. Medical expenses include, but are not limited to, medical services and fees, IV therapy, consumables. I agree my obligation to pay for Medical Expenses on appointment day and accept medical aids are not accepted as such an institution.  I agree that Saturn Aesthetics is not obligated to advance any payment(s) to cover Medical Expenses.

MEDICAL RECORDS CONSENT

CONSENT TO DISCLOSE HEALTH INFORMATION.

I authorize Saturn Aesthetics to keep a record of my medical history. I also authorize Saturn Aesthetics to release any information regarding Medical Care, which can include without limitation, medical history, symptoms, treatment, examination, results or diagnosis to your Medical Provider, in the event this is needed. I also hereby authorize Saturn Aesthetics to provide any necessary information to my next of kin of my condition. It has been explained to me that if I do not consent to any of the above, I may refuse my consent by deleting the relevant section(s). However, I acknowledge that if I withhold my consent for the transfer of medical records to any of the above, this may prejudice my treatment or that of the patient (in the case where the patient is my family member) and any issues associated therewith.

Do you currently have any of the following symptoms?

I certify that the medical information provided is correct and acknowledge that I have read and understood all the details in this form