I certify that the preceding medical, personal, and skin history statements are true and correct. I am aware that it is my responsponsibility to inform the technician or nurse of my current medical or health conditions. There are no refunds once you have signed this agreement. I understand that payment is due in full at the end of my treatment unless other arrangements were made prior to my appointment.
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OC Cosmetic and Vein Center offers aesthetic, cosmetic, and vein treatment services. All services are elective and provided by licensed professionals under applicable California laws.
No Guarantees- While we strive to deliver high-quality results, cosmetic and medical outcomes vary. No specific outcome is guaranteed. By accepting treatment, you acknowledge the risks and variability of cosmetic procedures.
Payment & Refund Policy- Full payment is due at the time of service. OC Cosmetic and Vein Center does not offer refunds on services rendered, including packages, due to the subjective nature of results. Prepaid services/packages expire 3 years from the purchase date unless otherwise agreed upon in writing.
Cancellation & No-Show Policy- We require a minimum of 24 hours’ notice for appointment cancellations. Failure to cancel within this window or not showing up will result in a fee up to $80, or forfeiture of a session if part of a package.
Eligibility- You must be at least 18 years of age or have written parental/guardian consent to receive services.
Privacy- All medical and personal information is kept confidential and handled according to HIPAA and California privacy laws.
Risks and Informed Consent- By undergoing treatment, you acknowledge that: You have received sufficient information about the procedure and possible risks. You have had the opportunity to ask questions. You are voluntarily electing to proceed.
Limitation of Liability- To the fullest extent allowed by law, OC Cosmetic and Vein Center and its providers shall not be liable for indirect, incidental, special, or consequential damages arising from treatment, even if advised of the possibility.
Arbitration Agreement- This Arbitration Agreement ("Agreement") is entered into by the patient and OC Cosmetic and Vein Center, including its agents, employees, and providers (A. Thomas Parsa, MD; Mubina Siddiqui, NP; and Neda Parsa, RN).
Agreement to Arbitrate- Any dispute, claim, or controversy arising out of or relating to services received at OC Cosmetic and Vein Center, including the interpretation, breach, or enforcement of this agreement, shall be resolved by binding arbitration rather than in court, except as provided under applicable law.
Scope- This agreement applies to any claims:For malpractice, negligence, or unprofessional conduct. Related to care rendered by OC Cosmetic and Vein Center or its providers that may arise after the termination of care.
Arbitrator Selection and Rules- Arbitration shall be conducted before a neutral arbitrator in Orange County, California, pursuant to the rules of the American Arbitration Association (AAA) or another mutually agreed-upon arbitration service.
Voluntary Agreement- You understand that by signing this agreement: You are waiving your right to a jury trial. Arbitration is the exclusive means for resolving disputes, except small claims or regulatory complaints.
Severability- If any part of this agreement is found unenforceable, the remainder shall remain in full force and effect.
Acknowledgment- By signing below or receiving services from OC Cosmetic and Vein Center, you acknowledge you have read and understand this Arbitration Agreement and voluntarily agree to its terms.
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Notice of Privacy Practices:
TO OUR PATIENTS:
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 Health Insurance Portability and Accountability Act of 1996.
Other Uses and Disclosures of PHI (Personal Health Information) Without Authorization: This Practice is permitted or required by the HIPAA privacy rule to use or disclose PHI without your written authorization as may be required by law or for the public-good. The uses and disclosures not otherwise described in this notice will only be made with your written authorization.
Your Individual Right:
Restriction Request: You have the right to request restrictions on the use and disclosure of PHI for treatment, payment or health care operations or that only certain individuals be involved in your care. Although the practice is not required to agree to such restrictions, we will accommodate reasonable requests, except when otherwise required by law.
Alternative Communication: You have a right to request alternate means communication. You may request that we contact you at a certain location or in a particular manner. We will accommodate reasonable requests.
Inspect and Copy: You have a right inspect and obtain a copy of your PHI and billing records. You must submit your request in writing to this practice's Privacy Official.
Amendment: You have a right to request an amendment to your PHI if you believe it is incorrect or incomplete. You must make your request in writing and submit it to the Privacy Official. You must provide us with a reason that supports your request for amendment.
Accounting: You have a right to receive an accounting of all disclosures of your PHI.
Paper Copy: You have a right to obtain a paper copy of this notice at any time.
Complaints: You have a right to file a complaint if you believe your privacy rights have been violated. This must be filled in writing with the Privacy Officer. You will not be intimidated, threatened, coerced or discriminated against for filing a complaint.
Privacy Officer: Any employee or physician of this Practice can provide you the name of the Privacy Officer, who can be reached at the address and telephone number on this document.
Effective Date: This notice takes effect upon acknowledgment by you.
The Medical Practice's Duties:
Legal Duties: This medical practice is required by law to maintain the privacy of your PHI and is required to abide by the terms of the "Notice of Privacy Practices".
Revisions: Revisions or amendments to this notice will be provided upon request and posted in the Reception Room.
Training: It is the responsibility of the practice to train its employees on current regulations. If they are unable to assist you, they will refer you to the Privacy Officer.
Right to Revoke This Authorizations: You may revoke this authorization at any time, except to the extent we have taken previous action based on the authorization.
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