Patient Registration Form

All accounts must be kept current and up to date. Payment is expected at the time of service. Payment can be made in the form of cash, check or credit card. There is a $25.00 fee charged for each returned check. Services bought as a package require 50% down at time of first service and 50% balance at time of second service. All products purchased must be paid for the same day they are purchased. If an appointment is cancelled with less than 24 hour notice or if an appointment is not kept, there will be a $50.00 fee charged to your account after the first occurrence.

I have completed the above information and confirm that it is correct. I agree that I have read and understand and agree to the Payment Information section above and consent to be a patient at Azura Skin Care Center, PLLC.

The Health Insurance Portability and Accountability Act {HIPAA) gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home.

View Notice of Privacy Practices

View Provider-Patient Arbitration Agreement