Sherman Oaks, CA
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Authorization for Release of information
1. I voluntarily consent to any and all health care treatment and diagnostic procedures provided by Sayana Medical and its associated physicians, clinicians and other personnel. I am aware that the practice of medicine and other health care professions is not an exact science and I further state that I understand that no guarantee has been or can be made as to the results of the treatments or examinations at Sayana Medical.
2. I agree to be contacted via email or SMS with information related to my visit, like: a patient portal invitation, post-visit satisfaction survey, appointment or checkup reminders, health tips, or new services that relate to me or my family.
3. I consent to the use and disclosure of my/the patient’s protected health information for purposes of obtaining payment for services rendered to me/the patient, treatment and health care operations consistent with Sayana Medical & Wellness Center Notice of Privacy Practices.
4. I authorize payment of medical benefits to Sayana Medical and Wellness Center.
5. I give permission to obtain all my medication/prescription history when using an electronic system to prescriptions for my medical treatment.
6. We require a 48-hour business notice to cancel or reschedule any appointments, a fee of $50 will be charged to the card on file if not cancelled within the policy.
New Patient Form will be submitted to Sayana Medical Spa and Wellness Center