Facebook Profile - Rejuvenis Facial Cosmetic Surgery & Medical Spa instagram - icon
217-398-4856
Trust Your Face To An Expert, Trust Your Face To A Facial Plastic Surgeon

Resource Center

New Patient Forms

Patient Financial Responsibility


Patient Name *

Patient Address *






Select a country:

Home Phone:

- -

Cell Phone:

- -

Work Phone:

- -

Email

Birth Date *

Practice May Speak With: *





Patient Financial Responsibility:



I accept financial responsibility for any products or services rendered by any employee of Rejuvenis Facial Cosmetic Surgery & Medical Spa. If a claim is submitted to my insurance company, I accept financial responsibility for any portion not covered by my insurance. If it becomes necessary for Rejuvenis Medical Spa to pursue collections, I agree to be responsible for any costs associated with collection, including, but not limited to court costs and reasonable attorney's fees. I further understand that there is a $27.50 fee for any returned check.


Please understand that when you do not cancel an appointment you are unable to keep, it may prevent other patients from receiving care. We ask that you notify our office 24 hours before your appointment if you need to cancel. We understand that there will be situations that involved medical emergencies or that are weather related.


I understand that failure to cancel in the appropriate time frame will result in the following charges applied to my credit card that is on file at the time I made my appointment. Should the credit card transaction be decline or you don't have my credit card on file, I will receive a statement. I further understand that these fees cannot be billed to my insurance carried and must be paid before any new appointments can be made for me. Continued no-show/no call or habitual cancellations may result in my dismissal from your practice. I understand that medical care will not be withheld in the event of an emergency.


Fees for no shows: $250-Consultation with Dr. Russo, $50-Consultation with Jennifer, our Patient Care Coordinator, $100 Injectable appointment (Botox and/or Filler), and $50 Medical Spa Consult. In the event your account is past due, it may be turned over to a collection agency. If your account is not paid in full and this account is turned over to a collection agency and/or attorney, then you agree to be responsible for all fees necessary for the collection of the delinquent account, including, but not limited to, collection agency fees of 50% of the balance due and costs and attorney's fee of 33% of the balance.





Electronic Signature *

Date *