TLC BUTTERFLY EFFECT SPA LLC

SPA ADMISSIONS FORM

 
 
Name *
Name
Permanent Mailing Address *
Permanent Mailing Address
Primary Phone *
Primary Phone
Other Phone
Other Phone
Work Phone
Work Phone
Date Of Birth *
Date Of Birth
Sex: *
May we contact you at: *
May we leave a message on you answering machine regarding results? *
May we leave a message with any other person? *
Please see your facial professional before beginning any facial treatment. There is a $25 fee NOT covered by any coupon presented upon service. This fee is for your required facial consultation in order to complete your procedure today.
Contact Number *
Contact Number
Phone Number
Phone Number
Is responsible party different from patient? *
Change in size, shape, color, or sensation in any moles or growths? *
Hypertension (HTN)(High Blood Pressure)? *
Hypercholesterolemia (High Cholesterol)? *
Liver disease *
Diabetes *
Neurological disorders *
Cancer *
Asthma/Allergies *
Thyroid disease *
Pacemaker *
Bleeding Disorder *
Cardiac Valve Disease/Mitral Valve Prolapse *
Joint Replacement *
Joint pain/arthritis *
Autoimmune disease *
Currently Pregnant *
Currently Breast feeding *
Current irregular periods *
Are you a? *
How often did you have a drink containing alcohol in the past year? *
Name
Name
Address
Address
Primary Phone
Primary Phone
Other Phone
Other Phone
Date of Birth
Date of Birth
Sex:
I authorize release of medical information to my Primary Care Dr.-Referring Physician/ other consultants if needed. *
Coach Scott recommends that all patients 20 & older have a comprehensive skin exam to screen for cancer. Please Choose One *
Phone
Phone
Address of Claim Center
Address of Claim Center
Insured's DOB
Insured's DOB
Policy Type
Employer Address
Employer Address
If patient is a child, select relationship
Do you have secondary coverage? *
The following are our conditions of registration as well as our policies with respect to the billing and collections of your account. By signing below, you are agreeing to be bound by these terms.
All co-payments, coinsurances and deductibles are due at the time of service. As a policy we will collect $45 at the time of visit to cover a portion of any consultation, coinsurance or deductible that may be due as we cannot determine these actual amounts until the claim has processed by our office manager.  We will can bill insurance carriers on your behalf if we have a current contract with the carrier. After your insurance has processed the claim, we will be able to determine whether any refunds are due for overpayments towards copayment, coinsurance or deductible and those will be sent to the patient. Please be advised that your agreement with your insurance carrier is a private one and that ultimately, you are responsible for payment. If an insurance carrier has not paid a claim within 30 days of billing, our fees are due and payable from you. Our office will always strive to help you obtain the maximum possible coverage. It is, however, the patient's ultimate responsibility to determine the extent of coverage allowed by the insurance company. In addition, preauthorization of a procedure is not a guarantee for payment. Any procedure may be considered not covered under the terms of your agreement with your insurance company. Your insurance carrier will make a determination of payment once the claim is received and reviewed. If after the claim is reviewed and it is determined by your insurance company that the procedure is not covered (cosmetic), you will be financially responsible to TLC Butterfly Effect Spa, LLC for the charges and will be billed for those services not covered by your insurance company.
Any care not paid for by your existing insurance coverage will require payment in full at the time services are provided or immediately upon notice of insurance claim denial.
In fairness to other patients and the doctor, we require at least 24 hours notice to cancel an appointment. You may be charged $50.00 for each appointment that was missed or not canceled with 24 hour notice. Missing more than two appointments without providing 24 hours notice is grounds for discharge from the practice.
There will be a fee of $35.00 charged by this office for each check returned to us by your bank.
In the event your account is referred to a collection agency or attorney for collection, you agree to pay all collection fees, attorney fees, court costs, and expenses.
Do you follow a structured skin regimen today?
Remove unwanted areas of fat?
Remove Cellulite
Tighten loose skin on arms, and above knees
Improve texture of skin (ex. Bumps on back of arms)
I have read, understood, and agree to be bound by the terms of this policy.
I hereby acknowledge that I had the opportunity to review the Notice of Privacy Practices of TLC Butterfly Effect Spa, LLC. I understand that the Notice of Privacy Practices sets forth my rights relating to the use and disclosure of my personal health information and explains how TLC Butterfly Effect Spa, LLC can use and/or disclose my personal health information both with and without my authorization. I understand that I am entitled to receive a copy of the Notice of Privacy Practices* if I so desire. I further understand that I may contact Coach Scott if I have any questions regarding the contents of this Notice of Privacy Practices or to file a complaint about the privacy practices of TLC Butterfly Effect Spa, LLC.