HIPAA Privacy Authorization Form

Notice of Information Practices. I understand that Skin and Tonic may use or disclose my personal health information (PHI) for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the practice. I also understand that Skin and Tonic will consider requests for restriction on a case by case basis, but does not have to agree to requests for restrictions.I hereby consent to the use and disclosure of my personal health information for the purposes as noted in Skin and Tonic’s Notice of Information Practices. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.I hereby authorize one or all of the designated parties below to request and receive the release of any PHI regarding my treatment, payment or administrative operations related to treatment or payment. I understand that the identity of designated parties must be verified before the release of any information.

Privacy Policy

We are committed to protecting your privacy and developing technology that gives you the most powerful and safe online experience. This statement of privacy applies to the Skin and Tonic website and governs data collection and usage. By using this website, you consent to the data practices described in this statement.

Collection Of Your Personal Information

• Skin and Tonic collects personally identifiable information, such as your email address, name, home or work address or telephone There is also information about your computer hardware and software that is automatically collected by this website. This information can include: your IP address, browser type, domain names, access times and referring website addresses. This information is used for the operation of the service, to maintain quality of the service, and to provide general statistics regarding use of this website.
• Please keep in mind that if you directly disclose personally identifiable information or personally sensitive data through public message boards, this information may be collected and used by others.
• Skin and Tonic encourages you to review the privacy statements of websites you choose to link to from the website so that you can understand how those websites collect, use and share your information. Skin and Tonic is not responsible for the privacy statements or other content on any other websites.

Use Of Your Personal Information

• Skin and Tonic collects and uses your personal information to operate the website and deliver the services you have requested. Skin and Tonic also uses your personally identifiable information to inform you of other products, promotions, or services available from Skin and Tonic and it’s Skin and Tonic may also contact you via surveys to conduct research about your opinion of current services or of potential new services that may be offered.
• Skin and Tonic does not sell, rent or lease its customer lists to third parties.
• Skin and Tonic may share data with trusted partners to help us perform statistical analysis, send you email or postal mail, provide customer support, or arrange for deliveries. All such third parties are prohibited from using your personal information except to provide these services and they are required to maintain the confidentiality of your information.
• Skin and Tonic does not use or disclose sensitive personal information, such as race, religion, or political affiliations, without your explicit consent.
• Skin and Tonic will disclose your personal information, without notice, only if required to do so by law.

Use Of Cookies

The website may use “cookies” to help personalize your online experience. A cookie is a text file that is placed on your hard disk by a web page server. Cookies cannot be used to run programs or deliver viruses to your computer. Cookies are uniquely assigned to you, and can only be read by a web server in the domain that issued the cookie to you.

Security of your Personal Information

Skin and Tonic secures your personal information from unauthorized access, use or disclosure. Skin and Tonic secures the personally identifiable information you provide on computer servers in a controlled, secure environment, protected from unauthorized access, use or disclosure.

Changes to this Statement

Skin and Tonic will occasionally update this Statement of Privacy to reflect company and customer feedback. We encourage you to periodically review this statement to be informed of how Skin and Tonic is protecting your information.

Contact Information

Please contact us by phone at 810-522-8411 or by mail at 113 W. Grand River Ave Brighton, Michigan 48116.

Cancellation, Reschedule and No Show Policy

• Skin and Tonic Requires a Credit Card on file for all scheduled appointments.
• Should you need to cancel or reschedule your appointment, please do so 48 hours prior to the scheduled appointment time.
• As a courtesy, we confirm appointments via text/email 2 days prior to scheduled appointments. If we have a cancellation on the schedule, we like to offer the time slot to a client on our waiting list, or those who are calling for a same day appointment.
• Without notice of cancellation we are unable to fulfill these When a client does not show up for a scheduled appointment, another client loses the opportunity to be seen, staff wastes time setting up, losses dependable income preparing for your appointment.
• It is to the discretion of Admin, to enforce a pre-payment for all future scheduled
• Should you need to do so in less than the required 48 hour notice period, you will be subject to a charge of $50 Reschedule/cancellation Fee.
• We reserve appointment times especially for you, please be considerate of your provider’s time and other clients needs.

• All clients that are scheduled, who do not show, will be charged a non refundable $50 fee via the CC on file as consented by this policy in scheduling an appointment and providing the required information.
• Clients with previous non show history, will be subject to prepayment for future appointment times.

I understand this policy is in place to assure the scheduled appointment, should it need to be rescheduled, it gives staff time to utilize/fill the appointment appropriately. The no show fee is to recover administrative costs of non attendance. Please try to abide by the 48 hours notice to avoid these fees. We understand that unplanned issues come up that require you to cancel/reschedule an appointment. Unfortunately, it has been our experience that most of the time unkept appointments are not due to emergencies. Thank you for being a valued client and for your understanding and cooperation in regards to this policy. I, as a client of Skin and Tonic, fully understand and agree to these policies and fees.

Late Arrivals

• We suggest arriving 5 minutes prior to your appointment time to allow time to complete paperwork (It is preferred if completed through your patient portal prior to scheduled visit) or answer any questions about your service you may have.
• We understand that issues can arise that may cause you to be late for your appointment. However, we ask that you call to inform us if that ever occurs, so we can do our best to accommodate you. Appointment times are reserved for each client’s specific needs, so oftentimes we cannot exceed that reserved If we are unable to accommodate your late arrival we will do our best to reschedule you the best we can.

Payment Agreement Policies

• Payment Agreement Questionnaires are required for all Service Packages, Treatment, Packages, and individual sessions.
• These rules apply to all purchases with or without a signed Payment Agreement Questionnaire.
• *Please refer to the questionnaire for details of Payment Plan specific to your purchase, which apply to the signing of this general agreement

The Following are the Payment Options decided on each individual purchase as agreed upon by management and the client prior to the scheduled service time:

1. PAYMENT IN FULL: Client Agrees to Pay such amount as follows: Choosing to Pay in Full and Enter the amount here.
2. PARTIAL PAYMENT WITH BALANCE DUE BEFORE 2ND TREATMENT: Client Agrees to pay such amount as follows: Application of X down Payment with a balance of X due Y.
3. 3RD PARTY PAYER: Client Agrees to Pay such amount as follows: Pursuant to the terms and conditions of an external Financial Agreement with a 3rd party lender in the amount of $XXXX, Subject to credit approval, releasing any and all rights to a refund of any kind if applicable once funds are transferred.
4. IN HOUSE FINANCING: I am in agreement to in-house financing of the terms of 6 or 12 months. With the first payment of $XXX due today and then followed by an automatic deducted amount of $XXX on XXXXX day of each month, followed by consecutive months XXXXX thru XXXX with a balance due of $XXXX by XXXX (please enter the details in this space).
5. MODEL AGREEMENT: I am entering into this payment agreement as a model agreement. I agree to receive a 50% discount on my services, whereby I am required to collect photos as instructed by staff, make postings as requested by staff, share my experience as a model, write a Google review of my experience and results. I acknowledge that should I fail to complete all these steps and treatments within the designated treatment time, I will be charged the full retail price by way of a credit card on file.
   
   • I understand that by default or failure to pay any amount due hereunder after a seven (7) day grace period, the customer shall be in default, and all amounts due under this agreement shall be accelerated and due immediately.
   • Customers shall owe Skin and Tonic a 20% late payment fee of the total remaining balance to cover its administrative costs if a customer remains in default for over forty-five (45) days. Skin and Tonic may retain a collection agency to recover the remaining balance, and the customer agrees to pay all collection agency fees if any.
   • All services will cease if default extends past the 7-day default grace period until payment in full is received.
   • By agreeing to this statement, I am held to this agreement and any consecutive future purchases.
   • I understand that there is no penalty for early payment.
   • I understand that there are NO refunds on any service or package once purchased for any reason.
   • I understand and agree that all treatments purchased are non-transferable.
   • If any treatments remain unused within 12 months of the purchase date, the client may submit in writing to Skin and Tonic and request a store credit towards another service similar in nature. All requests are subject to administrative approval and at the discretion of management on a case-by-case basis.
   • I agree to have my credit card information on file and for it to be auto-deducted per the terms of this agreement.
   • I fully understand and agree to the proposed treatment plan provided to me, and agree to pay Jenifer Gibson Staff Services LLC, DBA Skin and Tonic, the agreed-upon purchase price.
   • If I choose to utilize a Third-Party lender, I acknowledge that to be of my own free will. I clearly understand that my payment is for the treatment(s) performed during the term of the agreement and not for any specific result. No results have been guaranteed or implied.
   • I understand that results vary based on my adherence to pre and post protocols, variants in physiology, and the aging process.
   • I affirm that I have given all of my pertinent and relevant medical information to be evaluated for relevancy.
   • Any additional treatments discussed but not included in this agreement are at the client’s expense.
   • Any treatments required as a result of or complication of these services are at the client’s expense.
   • I understand that any other treatments discussed but not included in this agreement are subject to change and affirm that previous quotes are considered null and void at this time.
   • As an acknowledgment of this agreement, by way of scheduling my appointment, making a purchase in person or over the phone, I hereby agree to these terms.

Refund/Exchange Policy

• Refund Policy

  1. Most of our treatment plans consist of custom packaging of treatments. When factoring these prices, many factors are taken into account. Therefore, Skin+Tonic does not offer refunds or exchanges for any reason on services or products purchased, both used or unused.
  2. Please read all documentation provided prior to confirming your purchase by way of the required payment agreements, pre and post instructions, contraindication, possible complications and consent for treatment. 

  Exceptions:

  1. If there is an extenuating circumstance, the client may submit reasons for review. The case will be reviewed and a decision made within 30 days of receipt of request.
  2. Although refunds and exchanges are not offered.
  3. We do our best to satisfy the clients’ needs within reason.
  4. Should a client request an exchange of services, inform them to submit the request with reasons for request in writing via email skinandtonic.online@gmail.com. A decision will be made within 7 calendar days of the receipt of documentation requested.

  The Process for Exchange Reviews:

  1. Purchases of packages and series are given discounts. If a client has not rendered any of the treatments then the full amount will be considered for exchange based on a ROI per treatment, and assessed at full retail value, but no guarantee of exchange or refund is promised.
  2. Not all treatments can be exchanged “dollar for dollar”.
  3. In the case that a client has received some of the items in the package/series, the retail cost of those services rendered will be deducted and the remaining value will be the amount that is considered for exchange of another service.
  4. * All requests for refunds or exchanges must be submitted in writing to skinandtonic.online@gmail.com attention to management. Once any documentation requested is received, a decision will be made within 7 calendar days. This decision will be final and not eligible for reapplication of exception.
  5. All purchases that have not been rendered or submitted for review of exchange within 12 consecutive calendar months of purchase will be null and void and the client agrees to forfeit those services. Please keep in mind the cost of equipment, supplies, products is increasingly changing and we cannot offer any extensions beyond the 12 month period from date of purchase.
  6. Please know that our goal is to provide exceptional medical grade treatments and services. If a client’s needs dictate that a treatment purchased needs to be reviewed for alteration to the treatment plan, we will do our best to evaluate the case and provide the best alternative possible. We want you to achieve the end results you are looking for. Please know that Aesthetics is an art and a science, therefore reevaluation throughout the treatment plan is assessed by the provider, the nurse and the medical director.
  7. These policies are in place so that there is a guideline for staff to provide consistent care, safe and effective treatment results. When a treatment plan timeline is altered it can negatively affect the end results.  We try to be as accommodating as possible, but we also must have policies in place for those occasional situations that arise.
  8. We hope that you understand the documentation provided for your review at the time of purchase.

Laser Hair Removal Policy

• Laser Hair Removal is only sold as a package, unless approved by management with other terms specific to Laser Hair Removal Packages consist of an average of 8 treatments aiming for an approximate 70-90% reduction of hair growth, which is considered optimal. Provided the client remains consistent with the scheduled time frame of appointments set forth by staff for area of treatment, the purchaser is guaranteed to achieve a minimum of 70% of hair reduction. Treatments will be continued until reduction reaches this min.

• Clients then are able to schedule one touch-up at no charge per calendar year dating from the last treatment in the series that obtained a reduction of 70%. If a client was unable to maintain the required scheduling time frames, the yearly touch-ups will be at a cost of 50% of the individual pricing set forth in Services. This is subject to the discretion of the Skin + Tonic management.

• Clients purchasing after 4/1/22 receive yearly touch ups for area purchased at $99 per hour of treatment after original package is completed for the area purchased only.

Portal Policy

• All Clients are sent a HIPPA compliant portal access. This system is to be used for reviewing consents, pre and post instructions, scheduling and communication with staff. Information contained herein are for treatment and medical record Information is not shared with any 3rd party unless required by law.

Jan Marini and Epionce

• As clients of Skin and Tonic, you authorize the entering of your data to secure a custom purchasing account specific to your needs only linking each client to Skin and Tonic for purchasing future skin care products and grants access to educational information located on our website sections coded by member access.
• All clients are added to Jan Marini and or Epionce Skin Care Systems as determined by your skin care needs.
• At each appointment, this document is resigned, therefore reaffirming this.
• **If you wish to opt out of this, you must submit in writing to Skin and Tonic at 113 West Grand RIver Ave, Brighton Mi 48116 ATTN Management within 7 days of your first treatment rendered.

Membership Policies

• All locked Website access requires membership inquiry to be granted. Name, email, phone, and initial medical evaluation must be on file with the clinic and compliant with HIPAA regulations to access the restricted content.

• Membership monthly dues can be canceled at any time with 30 days written notice. Should your account be scheduled to process within the 30 day window it will process and post to your membership.

• Should a cc on file not process, client will be exited from the membership and not able to resubscribe if the account is not current within 7 business days.

Photo Consent

• All treatments are subject to before and after photos taken by staff and stored in your HIPAA compliant Staff will verify the photos taken for all intimate area treatments with clients prior to saving, to affirm discretion of area. This is a required document for skin integrity pre and post procedure.
• If a client refuses photos, treatments are subject to cancellation without refund. Management may consider a request for no photos if requested in advance of treatment, but retains the discretion of decision.
• There is NO photography in treatment rooms and or common areas by anyone other than staff unless authorized for Model Marketing purposes and in your model This is to safeguard client confidentiality and proprietary treatment protocols.
• ***Should this be violated, treatment will cease immediately, the client will not be eligible for refund.

Injectable Policy

• Dermafiller consults and/or appointments require $100 non-refundable deposit.
• Provided Neurotoxin recommendations are agreed on and injected as suggested at time of consultation, clients may receive up to 10 Units of Neurotoxin at their 10 day follow up for 50% off.
• We feel this is our responsibility and the window of adjustment. If you are a first time client, we tend to err on the side of caution starting with smaller doses to begin with is smart practice.
• If more than 10 Units are needed at your follow up, this would be due to your unknown muscle strength as a new face we are treating. Our Injector uses her training and judgment when recommending doses to start She also takes this information into consideration at your consecutive appointments and makes needed adjustments for future appointments to reduce the need for dose adjustments.
• If a client does not attend their 10 day follow up and or submit post photos then they forgo their discounted dose adjustment toxin pricing and are responsible for the cost of any additional toxin needed.

• Any follow up dose adjustments session beyond 15 days forgoes the reduced rate and any touch ups are at the client’s expense as well as additional Units needed or requested are at the clients expense.

**Cherry Financing Now Available and are subject to all standing policies*Please refer to the questionnaire for details of Payment Plan specific to your purchase, which apply to the signing of this general agreement.