Patient Waiver for the Clinic and Service Provider

I, the undersigned, hereby affirm and declare that I have provided the Practice and the service provider with all relevant information concerning my health profile during my pre-treatment examination. Additionally, I assure and warrant that I have disclosed all current medications to both the Practice and the service provider during the pre-treatment examination, specifying the source from which I obtain these medications, if applicable.

I acknowledge that the Practice and the service provider base their determinations on the complete disclosure I provide regarding all past and present medical conditions and history. I unequivocally waive any and all rights to any claims, including but not limited to monetary damages, against the service provider and the clinic, should it be discovered that false representations were made to them by me.

I am aware that in the event of losing medications, dispensed bi-weekly or monthly, I will not be able to obtain a new supply until the subsequent office visit, whether it occurs bi-weekly or monthly.

Furthermore, as a patient, I understand that if I seek treatment at another clinic or from another service provider during my ongoing treatment at Total Skin and Wellness, I am obligated to promptly and in writing notify Total Skin and Wellness and its representatives of any additional medications I may receive. Such written notification must be shared between this clinic, its representative, and myself, with the patient receiving a copy of this notification after its issuance.

As a patient, I have thoroughly read and comprehend this release. I am cognizant that this release constitutes a legally binding document.