Patients Visit Agreement


Patients Visit Agreement

  • ADVANCED DERMATOLOGY LASER & COSMETIC SURGERY
    1220 Avenue P                                         Brooklyn, NY 11229
    718-375-7546 (Tel)                                     718-376-6475 (Fax)
               CONSENT FOR OUTPATIENT TREATMENT
  • PATIENT OFFICE VISIT AGREEMENT

    I hereby attest that the information given to the Front Desk is complete and current.

    Any Bills resulting from inappropriate information including but not limited to inaccurate insurance card, inactive
    insurance card, and other insurance cards available not handed, or missing referral are my responsibility.

    Any bills resulting from Incomplete, inaccurate, or missing information will be my responsibility and will be
    paid by me in full.

    Any bills resulting from outstanding balance of Insurance Deductible will be my responsibility and have to be
    paid in full before I can see the Doctor.


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