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Waiver of Insurance
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* Indicates required question
Planned Procedure
*
iLux
IPL
Zest
Other:
Planned Date of Service:
MM
/
DD
/
YYYY
I agree to the following:
*
I understand that my services may be covered by my insurance. It is my wish to waive my insurance coverage and pay at the time of service.
I also understand that by waiving my insurance coverage, I release the physician and facility from any responsibility se forth in the insurance contract as a participating physician and/or facility for this procedure.
I further agree I will not file a claim in my own behalf to my insurance company.
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Patient Signature:
*
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Date of Signature
*
MM
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DD
/
YYYY
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