This page reproduces the Informed Consent & Financial Policy that every patient of Inside Out Medical Center reviews and signs in the clinic before treatment. A signed copy is completed in person prior to any procedure.
Informed Consent
I acknowledge that I have voluntarily chosen to receive treatment(s) and/or procedure(s) at this clinic. Prior to beginning treatment, I have had the opportunity to discuss the recommended treatment(s), expected benefits, potential risks, possible side effects, alternative treatment options, and post-treatment care instructions with my provider.
I understand that:
- The nature and purpose of my treatment(s) and procedure(s) have been explained to me in language I understand.
- I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction.
- No guarantees or warranties have been made regarding the outcome or results of any treatment or procedure.
- Individual results vary depending on factors including, but not limited to, age, medical history, lifestyle, skin type, healing response, and adherence to aftercare instructions.
- I agree to follow all pre-treatment and post-treatment instructions provided by my healthcare provider.
Financial Policy
I understand and agree that:
- All fees are non-refundable, regardless of the treatment outcome, my satisfaction with the results, or whether I start or complete the recommended treatment plan.
- Any prepaid treatment package, series, or service that has been started is non-refundable.
- Treatment estimates will expire 90 days after issue, at which point the patient will require a re-evaluation and a new financial agreement if care is delayed.
- I am financially responsible for all treatments and procedures that I authorize and receive.
- Missed appointments, late cancellations, or no-shows may be subject to the clinic's cancellation policy, if applicable.
The $200 consultation deposit is non-refundable. It is fully credited toward the cost of your treatment if you move forward with Inside Out Medical Center.
Acknowledgment
By signing the in-clinic form, I acknowledge that:
- I have received information regarding the treatment(s) and/or procedure(s) I am choosing to undergo.
- I understand the risks, benefits, alternatives, and expected recovery associated with my treatment(s).
- I understand the clinic's financial and refund policy.
- I understand that treatment estimates will expire in 90 days and that a re-evaluation and new financial agreement will be required if care is delayed.
- I understand that all treatments, procedures, services, and associated fees are non-refundable, whether I start or complete the recommended treatment plan.
- I consent to receive the recommended treatment(s) and/or procedure(s).
Policy version v.8/3/2026
Questions about this policy? Call 559-940-6990 or email [email protected].