Please read and place your name and signature at the end:

1. Consultation fee is $35 (Office Visit).
2. Follow-up fee (same problem) for consultation is $0, within 7 days.
3. Follow-up fee for lab results is $0, if less than 2 months from lab test payment date.
4. Prescription fee is $10 for controlled substances (Paper prescription).
5. Lab tests, medications, injections, among others are charged in addition to consultation fee (if any).
6. No refills will be issued, without Blood Works (Minimum required every 3 months).
7. Methods of payment are cash or credit card (No medical insurance accepted).
8. No insurance forms (i.e. disability, Worker’s Comp, and similar) completion will be provided.
9. Payments are collected in full.
10. There is no refund, after payment is processed.
11. There is no exchange of medications, after payment is processed.
12. No more than one family member is permitted inside the exam room w/ patient.
13. We reserve the right to refuse services to anyone.