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Patient Consent For Delivery & Payment (Form 3/4)

Please note, appointment reminders will be sent via text message to your cell phone. You will also receive a phone call or email to follow-up on first-time treatments.

By placing my signature below, I freely give the physicians and healthcare providers at the Washington Institute of Dermatologic Laser Surgery permission to treat my condition. I further understand that I will be charged/billed for consultations, treatments, and missed, or rescheduled appointments per office policy. A nonrefundable charge of $250 will be charged for each missed appointment or for every appointment canceled or rescheduled within 48 business hours.


There is a nonrefundable deposit of $1,000 required for the following procedures at the time of scheduling: CO 2 Laser, Coolsculpting, Instalift, Thermage, Ulthera.

I consent for clinical photographs to be taken as prescribed by my treating physician at any time during my care. I understand that the photos will be accorded the same privacy as my medical chart and that my consent can be withdrawn at any time (even after signing this consent form). I further understand that baseline (pre-treatment) and follow-up (post-treatment) photographs are essential to document my clinical progress and therapeutic response.

Who is authorized to receive patient medical information?
  • It is the patient’s responsibility to notify the office in writing with any changes to the information above.

  • Washington Institute of Dermatologic Laser Surgery does not participate with insurance companies.

  • Our physicians and staff members do not testify in court depositions, arbitrations, etc. relating to Worker’s Compensation or any other personal injury claims.

  • Full payment is required at the time of services rendered. Payment for services is solely the patient’s responsibility at (or before) the time of service. 

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