I clearly understand and agree that all services rendered by Dr. Mel's Wellness Spa or Dr. Mel Youngs D.C., P.A. are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care, that any fees for professional services rendered to me will be immediately due and payable. I understand that as I am accepted as a patient of Dr. Mel Youngs, D.C., P.A., & Dr. Mel's Wellness Spa Services, I authorize Dr. Mel and her staff to proceed with any spa services requested by me. Furthermore, any risks associated with the spa services provided, will be explained to me upon my request. We invite you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and patient.

I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.

I understand that Dr. Mel's Wellness Spa requires a 24 hour notice prior to cancelling or rescheduling an appointment. I am aware that if I do not call I will be charged a $25 cancellation fee. I have read and understand that my medical information is protected and completely confidential, consistent with the Health Insurance Portability and Accountability Act 1996 (HIPAA).

If today or in the future I choose to have electric muscle stimulation or ultrasound I give permission to perform the services and have reported any possible restriction to the staff.