Patient Information

Emergency Contact

***Authorization/Release of Health Information***

  • I hereby authorize PCH Medspa to release or obtain any medical information needed regarding my examination and/or treatment to my PCP/referring physician.
  • I hereby authorize photocopies of this form and my signature to be as valid as the original.

Patient Waiver/Financial Responsibility (All patients must sign)

By signing below, I understand that I will be responsible for the cost of all Medical & Aesthetic services rendered. I hereby authorize payment directly to PCH MedSpa (Swiftcare Medical Inc) at date of service. I agree to pay all outstanding balances at the time the services are rendered. I understand that all financial responsibilities will be my responsibility.

Notice to All Patients (All patients must sign)

Notice to All Patients (All patients must sign) By signing below, I understand that the time dedicated to my appointments/testing requires advanced planning on the part of PCH MedSpa. I further understand that if I do not show up for my scheduled appointment and I fail to call, cancel or reschedule the appointment I will be liable for a $50.00 to $100.00 no show fee; as such appointment could have been assigned to another patient.

For endolift patients there will be a charge of $1000 penalty on top of loss of deposit for any last-minute cancellations without legitimate reason ! ($500 penalty & loss of deposit applies to PDO thread patients)

Medication List


Medical History

Privacy Policy

HIPAA is the Health Insurance Portability and Accountability Act (HIPAA). It was put into place to protect patient privacy and to ensure privacy of all accumulated health information that belongs to the patient. It was signed into law in 1996 under the United States Department and Human Services. Healthcare providers nationwide were required to comply with rules and regulations of privacy protection by April of 2003. Your private health information is protected by federal law. You have rights regarding your personal information and it provides specific rules and regulations on who may have access to it.

The HIPPA agreement stated that you must be given the “Notice of Privacy Practices'' statement which belongs to the facility that you have an appointment with. The notice stated how the healthcare providers use the information from your personal medical file and when and who they can give the information to. If you are a regular patient at a facility, you may only have to sign the HIPAA paperwork once and then it will become part of your file. Some facilities do require you to sign one at every visit however, it depends on the policy of the facility.

Medical staff sign an agreement at least once a year, stating that they are aware of the provisions of the law, that they understand these laws and they will uphold these laws. These are kept on file at the facility at which they work. States may differ in their requirements, but the basic privacy laws must be upheld.

You can ask to see your records and to get copies of them at any time. You can have any corrections that you feel need to be made, included in your chart.

It protects any kind of health information such as office visits, tests, procedures, and diagnosis or other facets of medical care. Information that is spoken, printed or transmitted electronically all falls under the HIPAA privacy act. Your healthcare provider does have the right to share your information with:

  • Other healthcare professionals involved in your care
  • For coordination of your healthcare with other specialist/specialties
  • With any family, friend or other people that YOU determine as acceptable, to help with your medical care and/or finances and billing
  • Anyone directly involved in your care would have access to your information; doctors, nurses, other medical personnel, billing offices, any specialist, personnel who perform tests and/or procedures may also have access to your records for the time that you are in their care.

    Privacy Notice

    Acknowledgment of Receipt of Privacy Policy (original to be kept in patient’s medical records)

    By signing below, I acknowledge that I have read the office Privacy Policy Statement and I may request a copy for my records.