FINANCIAL POLICY & PAYMENT TERMS

PLEASE READ AND INITIAL EACH SECTION. THIS DOCUMENT IS A LEGALLY BINDING AGREEMENT.

📌 IMPORTANT NOTICE – NON-NEGOTIABLE TERMS

All deposits are strictly non-refundable, regardless of the timing of cancellation—even if canceled within the hour of booking.

No cancellations or refunds are allowed for out-of-town treatments (e.g., NYC, Miami) due to travel costs, staffing, and high demand.

All credit card convenience fees are non-refundable.

Failure to complete required preoperative clearances at least 14 days in advance will result in forfeiture of all monies paid and surgery cancellation.

Consultation fees are valid only for use with the specific provider the consultation was scheduled and paid for. Consultation fees must be used within 90 days and may not be applied to any other provider, service, or product.

PREOPERATIVE CLEARANCES

(Initial here: _____)
 All surgical patients must provide the following clearances at least 14 calendar days prior to surgery:

  • Medical History and Physical
  • Cardiology clearance with Letter of Clearance
  • Bloodwork (CBC, CMP, Coag Panel), EKG, and Chest X-ray
  • Mammogram or Ultrasound for breast-related cases

Clearances are valid for 30 days from issuance. Failure to submit by the deadline results in automatic cancellation and forfeiture of all monies.

GENERAL PAYMENT TERMS

(Initial here: _____)
 Quotes are valid for 90 days. Consultation fees apply only to the provider seen and cannot be transferred.

Payment Deadlines:

  • West Hollywood Clinic: Full payment due 14 days before treatment.
  • Out-of-Town Procedures (NYC, Miami): Payment due 20 business days (4 weeks) prior.
  • Surgeries: Full payment due 20 business days before surgery.

All credit card convenience fees (3.99%) are non-refundable under any circumstance.

RESERVATIONS & DEPOSITS

(Initial here: _____)
 All reservations require a 20% non-refundable deposit.

  • Deposits apply to the booked service only.
  • Deposits are non-transferable and non-refundable even if canceled immediately after booking.
  • They cannot be reassigned to another procedure or person.

CANCELLATIONS & REFUNDS

(Initial here: _____)

  • >20 business days before: 20% deposit is forfeited; balance refunded.
  • ≤20 business days: All funds forfeited.
  • Skincare and aftercare products/services are FINAL SALE, even if unused.
  • No-shows or refusal to undergo treatment = full cost forfeited.

POSTPONEMENTS & RESCHEDULING

(Initial here: _____)

  • >20 business days’ notice: Deposit is forfeited.
  • ≤20 business days’ notice: All payments are forfeited.

NON-SURGICAL TREATMENT POLICIES

(Initial here: _____)

  • No-shows or late cancellations = 100% fee forfeiture.
  • Unpaid appointments will be charged to card on file.
  • All payments are final and non-refundable.
  • CONSULTATION FEE POLICY

(Initial here: _____)

  • All consultation fees are non-refundable.
  • Arriving 15+ minutes late = appointment canceled and full fee forfeited.
  • Patient must arrive at least 30 minutes before procedures for check-in/photos.
  • Patient portal and paperwork must be completed at least 24 hours prior.
  • Rescheduling after forfeiture = full repayment required.

DISCOUNTED PACKAGES, BUNDLES & PROMOTIONS

(Initial here: _____)
 (Discounted-Package Initials: _____)
 All discounted packages (e.g., multiple lasers, multiple syringes, combo surgeries, botox banking):

  • Valid for 6 months from purchase.
  • Must be paid in full upfront.
  • No partial refunds if only some treatments are used.
  • No transfer, no substitutions, and no conversion to credit for other services.
  • Surgery deposits not scheduled within 6 months are forfeited.

MEDIA RELEASE, SOCIAL DISCOUNT AGREEMENT & REVOCATION PENALTY

(Initial here: _____)
 Patients receiving discounts in exchange for media (e.g., photo/video/social content):

  • Grant irrevocable consent for use of their images, videos, and testimonials.
  • Cannot revoke consent after treatment or publication.
  • If revoked or disparaged after posting, the patient agrees to pay 5x the full treatment cost to cover overhead, media production, staff time, and damages.
  • Legal action will be taken if consent is revoked after content is used.

OUTCOME DISCLAIMER & RESULTS WAIVER

(Initial here: _____)
 Patients understand that:

  • Results are not guaranteed.
  • No specific outcomes or improvements are promised.
  • Complications (e.g., scarring, pigmentation) are known risks and do not warrant a refund or free retreatment.
  • If patient declines a recommended procedure (e.g., surgery) and opts for a lesser option, dissatisfaction from that choice is not the practice’s responsibility.

If the patient publicly shares false information (e.g., social media, Google reviews, Reddit, group chats), or files a false complaint with the medical board, they agree to:

  • Be liable for all damages, including lost revenue, staff time, attorney fees, and emotional distress.
  • Pay liquidated damages up to 5x the cost of the procedure if actual loss is not quantifiable.

DISPUTE RESOLUTION & ATTORNEY FEES CLAUSE

(Initial here: _____)

  • All disputes must be submitted in writing before any third-party complaint.
  • All claims will be handled via binding arbitration under California law.
  • Attorney’s fees, court costs, and lost time compensation will be paid by the losing party.
  • Claims of defamation or fraud will be pursued to the fullest legal extent, including claims exceeding the original treatment cost.

CHARGEBACK POLICY (ANTI-FRAUD MEASURES)

(Initial here: _____)
 (Chargeback Initials: _____)

  • Chargebacks are treated as fraud and will be prosecuted.
  • Any chargeback = immediate termination of patient relationship.
  • Patient responsible for all legal fees in recovering funds.
  • Overages for surgery/anesthesia are not eligible for chargebacks under any circumstance.

OVERAGES

(Initial here: _____)
 (Overage Initials: _____)

  • Procedure and anesthesia times are estimates and may increase.
  • You authorize charges for additional time.
  • These fees are mandatory and non-disputable.

COLLECTIONS

(Initial here: _____)

  • Unpaid accounts may be sent to collections.
  • Patient is responsible for 35% collection fees and any attorney/legal costs.
  • Clinic may contact via phone, text, email, or automated methods.

PAYMENT METHODS

(Initial here: _____)
 Accepted forms: Cash, Wire Transfer, Cashier’s Check, Credit Card, CareCredit, PatientFi, Alphaeon, Zelle, Alle.
3.99% processing fee applies to all credit card transactions.

SMS/TEXT MESSAGING TERMS AND CONDITIONS

  • Program Description: By providing your mobile phone number and opting in to receive text messages from Dr. Jason Emer MD / Emer Medical, you consent to receive recurring automated SMS/MMS messages including: appointment reminders, appointment confirmations, pre/post-procedure instructions, promotional offers, and practice updates.
  • Consent: By submitting your phone number on our website, checking the SMS opt-in box, or texting a keyword to our number, you expressly consent to receive text messages from Dr. Jason Emer MD. Consent is not a condition of purchase or service.
  • Message Frequency: Message frequency varies based on your interactions and appointments. You may receive up to 10 messages per month.
  • Opt-Out: Text STOP to any message to unsubscribe from future SMS messages. You will receive a confirmation message.
  • Message & Data Rates: Standard message and data rates may apply. Check with your mobile carrier for details.
  • Carrier Liability: Carriers are not liable for delayed or undelivered messages.
  • Privacy: Your mobile number and opt-in data will not be shared with third parties or affiliates for marketing or promotional purposes. We will only use your information to send messages related to our services.
  • Supported Carriers: Major US carriers are supported including AT&T, Verizon, T-Mobile, Sprint, and others.

✅ ACKNOWLEDGMENT & SIGNATURE – MANDATORY LEGAL CONSENT

By signing below, I confirm that:

  • I have read and fully understand this policy.
  • I agree to all cancellation, refund, arbitration, and dispute terms.
  • I waive my rights to initiate chargebacks or request refunds unless mandated by law.
  • I understand this document is legally binding, enforceable, and compliant with CA, NY, and FL law.
  • I authorize electronic signatures as valid under the U.S. E-SIGN Act.

Signature: __________________________
 Date: __________________________
 Printed Name: __________________________
 Witness (Staff): __________________________

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