I consent for medical photographs to be taken of me by the staff of Nash Dermatology for identification purposes and medical treatment. Photographs are generally only taken, if necessary, to help ensure accuracy of medical information in your chart, including correct site identification for procedures, monitoring skin lesions, or rashes. Photographs may be shared with other members of your medical care team (PCP or specialists) to help avoid medical errors in identifying treatment sites. Please check the box at the bottom of this paragraph if you are refusing consent. This decision will in no way affect the medical care you will receive. If I wish to withdraw consent in the future, you may do so with a written request. PHOTOS WILL NOT BE POSTED TO SOCIAL MEDIA. Consent to be Photographed I do not consent to have any photographs taken at this time No Show Policy At Nash Dermatology, we know how valuable your time is and we strive to provide patients with timely access to care. When patients do not show for an appointment, it is taking an appointment slot away from another patient who needed care. We provide multiple appointment reminders as we know that schedules get busy and sometimes you may forget about your scheduled appointment. We require at least 24 hours’ notice if you need to cancel or reschedule your appointment, or it will be considered a NO SHOW. You may be charged a fee of $50 for missed appointments (“no show”). This fee will be billed to you, this is not covered by insurance and must be paid in full prior to your next appointment. We have a 3-strike policy: On the first NO SHOW you will receive a letter reminding you of the policy. On the second NO SHOW you will receive a letter reminding you of the policy and may be charged $50, along with a friendly reminder that any further missed appointments will result in dismissal from the practice. In the unfortunate and unlikely event that a third appointment is missed in any given 12-month period, you will receive a dismissal letter from the practice, and we will forward your records to the provider of your choosing. We do understand that emergencies and unexpected circumstances arise. Please communicate with us early and often regarding your appointment so that we may continue offering exceptional service. By signing below, you acknowledge that you understand both of these policies. Name(Required) First Last Patient or Legal Guardian Signature(Required) Reset signature Signature locked. Reset to sign again Date(Required) MM slash DD slash YYYY Δ
