In our ongoing efforts to provide you with the best possible service, we ask that you carefully review this consent form and ask any questions necessary to help you fully understand it.
Disclosure of Medical History
I agree that I will disclose a full and accurate personal medical history, including any and all information regarding medical conditions and my use of medications, skincare products, drugs, herbs, vitamins, or other supplements of any kind. I understand that failure to do so may affect my treatment outcome and increase the likelihood or severity of complications.
Confidentiality/Privacy Practices/HIPAA Authorization and Informed Consent
I understand that no information regarding services performed shall be released without my express consent except as follows: I authorize that copies of my records may be sent to another location if I seek additional treatment at that location or requests by legal entities. I understand that, in addition to authorized clinic personnel, the clinic’s medical director and consulting physicians/specialists/company representatives shall have full access to my treatment records. I understand that an appropriate medical review may be conducted to further the safety and efficacy of my services. I understand my provider may also provide limited non-identifiable patient information to various third-party vendors to provide database development and maintenance services, referral services, or marketing research services. I understand that photographs may be taken to document treatment results, but they will not be released or used otherwise without my specific written consent. My provider will maintain file copies of all records for a minimum of three years.
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.
The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.
You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.
Skincare Products
I understand that some of the skincare products offered by my practitioner are professional strength and formulated to aggressively treat problematic skin. I agree that I will use any skincare products obtained from the clinic in accordance with the instructions and directions provided to me by the clinic staff and only after becoming acquainted with the product and its recommended use. I realize that I may experience varying degrees of discomfort, redness, burning, peeling, itching, dryness, or other symptoms, especially in the early stages of use. These symptoms should lessen and eventually subside as my skin tolerance develops. I understand that in unusual circumstances, use of these professional strength products could be harmful and even cause injury to the skin (infection, discoloration, superficial scarring, etc.). I will discontinue use and notify my practitioner if any unusual or concerning irritation occurs. I will not use any of these professional strength products if I am nursing, pregnant, or trying to become pregnant. I understand that long-term use is necessary to achieve and retain the desired benefits and that it may take several months before a noticeable difference or goal is achieved.
Continued Consent
I understand that services generally consist of a series of treatments to achieve maximum benefit, and this consent shall apply to all services rendered to me by my practitioner, including ongoing or intermittent treatments.
Cancellation and Timeliness Policy
ANYASolutions is committed to providing all of our clients with exceptional and timely care. When a client cancels without giving enough notice, they may prevent another client from being seen. Please call or text us at (615) 485-5293, email us at [email protected] or send a message in your client portal by 2:00 p.m. on the day prior to your scheduled appointment to notify us of any changes or cancellations. If the appropriate prior notification is not given, you will be charged a minimum of $45.00 and up to the cost of the service for the missed appointment and/or forfeiture of any associated voucher, gift card, or deposit(s) made upon the appointment.
Please ensure that you have logged in to your patient portal and completed any necessary paperwork at least 24 hours prior to your appointment. Failure to complete paperwork prior to your scheduled appointment time may result in a reduction of your available treatment time.
Front Desk Policy
Please respect the tranquility of other guests and refrain from phone conversations and loud noises that may disrupt others in the clinic during your visit.
Gift Certificate & Gift Card Policy
Gift Cards/Certificates are non-transferable, non-refundable, and cannot be redeemed for cash or gratuities. Gift Cards/Certificates can be used for all products and services and are valid for 1 year from the date of purchase.
Payment Policy
Because our practice is limited to elective aesthetic procedures, we do not bill insurance. Payment for all individual treatments is due at the time of treatment, and all packages must be paid in full at the time of the first treatment. Feel free to inquire about limited 3rd party financing plans. All services are final sales; there are no refunds or credits issued for any service or gratuity. We accept cash, Visa, MasterCard, Discover, American Express, Cherry financing, and Care Credit. All prices are subject to change without notice.
Prices & Promotions
We are committed to continuously expanding our services to ensure we bring you the latest and greatest technology. Although we make every effort to keep our website, social media, and spa menu/print materials updated accordingly, please note that prices, services, and products are subject to change at any time without notice. Special offers and discounts may not be combined. When presented with more than one discount opportunity, we will automatically give clients the discount of greater value at the time of purchase.
Gratuities
Gratuities are at your discretion and are always appreciated by our professionally trained staff. Aesthetic services automatically include a 15% gratuity, the industry standard is between 15-20% of the full-service cost of each individual service, and what you choose to give depends on your level of satisfaction.
Refund Policy
We do not offer refunds on services rendered. Aesthetic results are quite variable from person to person and while we do our best to achieve the desired outcome, it cannot always be guaranteed. Clients are responsible for further treatments needed to achieve further results.
Products: We do not offer refunds on products purchased. Products may be returned for in-store credit within 14 days from the date of purchase when there is a documented adverse reaction to the product. Defective products (i.e., a broken pump) may be exchanged within 3 days for the same product only.
Referral Policy
Refer a New Client to our practice and receive a credit towards any service on your account after the New Client’s first treatment is complete, this credit varies depending on the current promotion. You must use your credit within one year. There is no cash value associated with this credit to your account as it will only be applied toward a service or product.
Treatment Expiration
Service packages and pre-paid treatments must be used within 12 months of the date of purchase or they will expire unless otherwise specified in writing.
Treatment Outcomes
We will be honest in all our dealings with you as our trusted client. Aesthetics is not an exact science and how you may respond to a given treatment will vary from person to person. It is virtually impossible to predict results and therefore payments made for services are for treatments to be performed – not for a specific result. However, we always strive to achieve the absolute best result that we can for you. Thank you for allowing us to serve you!
Personal Belongings
Personal belongings are the full responsibility of the clinic guest and should be kept in your possession at all times. ANYASolutions, LLC is not responsible for lost or damaged items.
Full Disclosure
Our #1 goal is for you to be happy with our service and to love the results you achieve. We believe in full disclosure, which means we strive to ensure that you understand the treatments you receive and the risks and benefits associated with each of them. With this in mind, please be assured that our team will only recommend treatments and products that will benefit you specifically, and which are medically appropriate for you. If you have any questions, at any time, please ask! We are here to help!
Practice-Patient Relationship
We love our clients but sometimes we have to reserve the right to refuse service at any time, to anyone, for any reason. ANYASolutions is a proud member of the Better Business Bureau and the Denver LGBTQ Chamber of Commerce.
