Plastic, Reconstructive & Aesthetic Surgery Intake Form

Please provide us with your insurance details.

Note: Cosmetic services are generally self-pay. Reconstructive coverage depends on medical necessity and plan rules.

Please tick all that apply and provide details where requested.

To be completed by the Patient or parent/guardian/caregiver 

To be completed by the Patient or parent/guardian/caregiver 

Select all that apply

Questions relevant to first-degree relatives.

Complete as Applicable

I agree to the following:

1. Please note that Co-pays are collected at the time of visit.

2. I authorize the release of any medical records or other information necessary to process this claim. I understand that all medical records will be stored on a secure, encrypted server for 7 years. I understand that my data is collected, stored and shared as needed and is handled in compliance with the data protection law.

3. I understand that all treatment fees will be billed directly to my insurance company provider. Please note that we charge the SHIC customary health insurance charges.

4. I authorize NovoClinic to verify my health insurance benefits. I will be responsible for all co-pays/co-insurance and deductibles that may apply.

5. I understand that I will be responsible for all rejected amounts billed to my insurance provider for services rendered by the medical practitioners of NovoClinic.

6. I understand that any amounts outstanding for more than 90 days will be send for debt collection through the appropriate channels.

7. I grant permission for licensed medical practitioners at NovoClinic to perform such examinations and medical treatments as may be professionally deemed necessary or advisable for appropriate evaluation and treatment of my condition. I understand that I will be given all available pertinent information prior to treatment being rendered. I will be given the opportunity to ask questions and to have them answered to my satisfaction.

8. I understand that I may decline treatment at any time.

Data Protection / Privacy Notice Acknowledgement

10. I understand the clinic will process my personal data (including health information) for providing care, administration, billing/insurance, quality/safety, and legal/regulatory obligations, consistent with Cayman Islands data protection law.

Consent to Disclose Information (Care Coordination & Billing)

11. I authorise the clinic to share relevant information with my GP/referring doctor, laboratories/imaging, pharmacy, hospitals/other providers, and my insurer/claims administrators as required for pre-authorisation and claims.