Terms of Virtual Assessment
& Privacy Consent
Please read the following Terms of Virtual Assessment & Privacy Consent carefully before proceeding.
By submitting the virtual assessment form, you acknowledge that you have reviewed, understood, and agreed to the terms outlined below.
Preliminary Feedback Only: I understand that this virtual assessment is a preliminary screening and not a physical examination, medical diagnosis, or definitive treatment plan. Bella Mae Plastic Surgery’s feedback is based solely on the images and information I have provided.
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No Physician-Patient Relationship: I understand that submitting this form does not establish a formal physician-patient relationship. Such a relationship is only formed after an in-person or virtual face to face consultation and the execution of a formal surgical agreement.
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Accuracy of Information: I certify that the photos and medical data provided are accurate and represent my current physical condition. I understand that a physical exam is required before any surgery.
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Telehealth Risks & Privacy: I have read and agree to the HIPAA and Website Privacy Policy. I understand the inherent risks of electronic data transmission. I consent to the storage of my photos in my secure medical record for assessment purposes only; these images will not be used for marketing without my separate, written consent.
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Communication: I consent to receive email and SMS updates regarding my assessment. For SMS, message and data rates may apply. I can reply STOP at any time to opt-out.
Medical Emergencies: I understand this form is not for urgent matters. If I am experiencing a medical emergency, I will call 911 immediately.