Per HIPAA regulations, your health information is kept private. This waiver allows Mahsa A. Sohrab, MD to share or receive your medical data only as specified below.

I grant permission to the staff of Mahsa A. Sohrab, MD to take photographs of me for the following purposes:

• Clinical Records: To document my response to treatment and assist in clinical decision-making. (Required for treatment)
• Educational & Social Media: Optional.

We value your time and prepare extensively for your visit. Therefore, a $250 fee applies to no-shows or cancellations of cosmetic appointments with less than 24-hour notice.

A non-refundable $750 deposit is required to secure your surgical appointment. We kindly ask for at least 10 days' notice for any rescheduling or cancellation. Please ensure your balance is paid in full no later than 15 days before your surgery date; if payment is not received by this time, the appointment will be automatically canceled.

Payment Methods: We accept cash and all major credit cards as payment forms.

I understand that the cosmetic services and procedures I am requesting are elective and not covered by Medicare. I agree that neither I nor the practice will submit claims to Medicare for cosmetic services that are legally excluded from Medicare coverage. I understand that I am personally responsible for the full cost of all cosmetic procedures, consultations, facility fees, anesthesia fees, postoperative care, and any related services not covered by Medicare. Patient Initials (if applicable):

I have read, understood, and agree to all the above financial policies and office policies of Mahsa A. Sohrab, MD. I certify that the information provided is correct to the best of my knowledge.