Page 6 - Forms - New Patient Paperwork (Dec-2017)_Neat

AUTHORIZATION FOR EXAMINATION
I, ________________________________________________, represent to the surgeons and staff that I am at 18 years of age, or, if
not, am accompanied by a parent or legal guardian. I hereby consent to and authorize examination and treatment by the doctor,
nurses and/or other assistants and staff, as may be assigned by him/her. I hereby voluntarily grant permission to The Swan Center for
Plastic Surgery and/or their designated employees to take and use any pre-operative photos of myself for purposes of consultation and
medical record. In the event of any litigation arising from treatment, I agree to submit case to arbitration.
Signature: ____________________________________________________ Date: _____________________
Relationship (circle one): PATIENT PARENT GUARDIAN
FINANCIAL AGREEMENTS
I authorize The Swan Center for Plastic Surgery to release any medical information requested by representatives of local, state, or
federal agencies, insurance companies, or other organizations and entities, as may be required by said representatives for payment of
claims arising out of medical rendered by The Swan Center for Plastic Surgery d/b/a Plastic Surgery Associates of Atlanta.
I understand payment for surgical services is due prior to services being rendered unless other documented arrangements have been
made in advance. I understand acceptable payments to The Swan Center for Plastic Surgery include: cash, check, American Express,
Visa, Discover, and MasterCard. I further understand if, for any reason, my account balance remains outstanding thirty (30) days past
the date services were provided, interest will accrue at 1.5% per month, and any legal fees incurred by The Swan Center for Plastic
Surgery d/b/a Plastic Surgery Associates of Atlanta, to collect monies owed, will become due and payable by myself (the patient),
or parent/guardian, if I (the patient) am a minor.
Furthermore, I understand that cosmetic consultations are complimentary, but there may be a consultation fee for the initial visit, if it
is deemed reconstructive in nature., and this fee is due at the time of my appointment, unless other arrangements have been agreed
upon and documented by The Swan Center for Plastic Surgery.

Signature: ____________________________________________________ Date: _____________________
Relationship (circle one): PATIENT PARENT GUARDIAN
PHOTOGRAPHY/VIDEOTAPING CONSENT & RELEASE
I hereby acknowledge and grant permission to The Swan Center for Plastic Surgery and their designated staff to take and use any pre-
operative (before), intra-operative (during), or post-operative (after) photographs of my body, and parts thereof, over the course of my
treatment, for purposes of record, research, education, marketing, medical publication, as well as assisting others in making their
surgical decisions. I understand that such imaging records may be published by The Swan Center for Plastic Surgery and/or any party
acting under the authority of The Swan Center for Plastic Surgery in any print, visual, or electronic media, including but not limited to
medical journals, scientific presentations, educational courses, marketing materials, social media, and The Swan Center for Plastic
Surgery website and its’ related entities. I understand these imaging records may be used to inform the medical profession or general
public about cosmetic and plastic surgery methods, techniques, results, issues, trends, concerns, and similar topics of interest. I further
understand I have the right to revoke this authorization, notwithstanding any prior use, by providing written notification to The Swan
Center for Plastic Surgery.
I give my consent as a voluntary contribution in the interest of public education, and my consent is subject only to the condition I am
not identified by name at any time during any use or publication of these materials by any party. Further, I release and discharge The
Swan Center for Plastic Surgery and all parties acting under their license and authority, from any and all claims or actions that I have
or may have relating to such use and publication, and all rights, if any, that I may have in such photographs and/or videos and details
regarding services rendered me, including any claim for payment, in connection with any such use or publication.

Signature: ____________________________________________________ Date: _____________________

Relationship (circle one): PATIENT PARENT GUARDIAN

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