Demographic & Medical History *
The patient demographic and medical history information provided is true and correct as verified by myself.
HIPAA Privacy Notice *
Contemporary Plastic Surgery is in compliance with the HIPAA Omnibus Final Rule 2013. The notice of health information privacy policies for Contemporary Plastic Surgery will have been presented for review by the patient prior to being seen. By signing below, he/she acknowledges that he/she has been presented with a copy of Vaishali B. Doolabh, MD Notice of Privacy Practices, and has had an opportunity to ask any and all questions to their satisfaction, and is signing below voluntarily.
This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPPA). Contemporary Plastic Surgery may provide marketing
Contemporary Plastic Surgery is licensed and dispenses limited pharmaceuticals, such as Tretinoin Cream, 4% Hydroquinone and Latisse. These prescriptions may be filled in this office or any pharmacy.
Credit Card Use *
In the event that you use a credit card and initiate a chargeback, your signature below gives Contemporary Plastic Surgery permission to transmit your medical records to your credit card issuer.
Notice of exclusions from insurance benefits, including Medicare *
By signing below you, acknowledge that you understand in advance, cosmetic procedures do not meet the definition of a covered benefit and cannot be filed with your insurance carrier, including Medicare, for reimbursement. All procedures performed in this office are cosmetic and no insurance, including Medicare, will be filed by Contemporary Plastic Surgery or the patient.
Appointment Cancellation Policy *
We strive to provide excellent care to you and all of our patients. In order to do so, effectively and efficiently, we have developed an appointment system that sets aside ample time for a patient. “No-shows” and late cancellations inconvenience those individuals who need access to our services in a timely manner. In an effort to reduce the number of such occurrences, we have implemented an Appointment Cancellation Policy and it is effective immediately. Our policy is as follows: (1) We request you give our office at least 24 hour notice in the event you need to reschedule your appointment. Our phone number is 904-854-4800. (2) If you miss an appointment and do not contact us with at least a 24 hours prior notice, we will consider this a missed appointment and a $50.00 no-show fee with be assessed to you. This applies to late cancellations and “no-shows.” (3) If you are more than 15 minutes late for an appointment, you will have to be rescheduled. We would not have the proper amount of time to complete your appointment. You will be required to pay a $50.00 deposit to secure your next appointment. This deposit will be used towards your service for that appointment. If you miss that appointment without providing 24 hours prior notice, the $50.00 deposit will be retained as a no show fee. (4) Our office makes reminder calls for appointments. It is ultimately the patient’s responsibility to remember their scheduled appointments. The cancellation fee must be paid prior to your next appointment. Thank you for trusting Contemporary Plastic Surgery to care for you. I have read and understand the Appointment Cancellation Policy and agree to the terms of this policy.
Healthcare Recordings *
To ensure confidentiality and privacy, any type of electronic recording with mobile devices is strictly prohibited at any location within these offices. The office does use security surveillance cameras. Recording discussions about health care via video or audio is not a substitute for listening, and breaches the confidentiality rights of other patients and employees. You, the above named patient, agree that by signing below, your agreement or consent will be legally binding and enforceable, and the legal equivalent of your handwritten signature.