Emergency Contact

Whom Do We Have the Pleasure of Thanking for Referring You?

Medical History

Pharmacy

Cosmetic Questionnaire

SkinCeuticals NicholsMd of Fairfield by NicholsMD of Greenwich has a curated menu for selective luxury services in under an hour. Below is our full menu of services, available at NicholsMD of Greenwich. For our entire Before and After Gallery.

SPECIFIC AREAS OF CONCERN

Please Select Your Skin Concerns Below:

NOTABLE PROCEDURES OF INTEREST

Please Select Your Procedures of Interests:

WHAT IS YOUR CURRENT SKINCARE REGIMEN?

Financial Policy

Payment is due in full at the time of service for consultations, examinations, and procedures. We accept cash, checks, and all major credit cards. As a courtesy, we also offer Care Credit™, a credit card financing program for cosmetic procedures. Please ask for more information if you are interested. All fees, deposits, and procedures done at NicholsMd of Fairfield are considered services rendered, and thus, are non-refundable. All skin care products purchased are final sale. Our office will keep your credit card on file in order to expedite checkout transactions, charge non-refundable deposits towards specific appointments, and/or cancellation etiquette breaches. The credit card number is kept in a secure program in our system.

​Cancellation Etiquette

SkinCeuticals NicholsMd of Fairfield by NicholsMD of Greenwich has a 24-hour cancellation policy. All appointments canceled less than 24 hours prior to the appointment will be charged $175.

Authorization, Assignment and Acknowledgment

By signing this document you have been made aware and agree to our financial and cancellation policies.

Photography Release Form

These photographs will ONLY be used for my patient care. I ____________________, understand that taking medical photographs is an important part of patient care. Thus, I authorize NicholsMD of Fairfield, Dr. Kim Nichols and staff representatives, to take photographs of my body for medical purposes.

NOTICE OF PRIVACY PRACTICES CONSENT

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The Patient Understands That:

• Protected health information may be disclosed or used for treatment, payment, or health care operations
• The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice
• The Practice reserves the right to change the Notice of Privacy Practices
• The Patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions
• The Patient may revoke this Consent in writing at any time and all future disclosures will then cease
• The Patient may condition receipt of treatment upon the execution of this

Authorization, Assignment And Acknowledgment

My signature below indicates that I have read and understand this consent in its entirety, that my questions have been adequately answered, and that a copy of the Notice of Privacy practices is available to me upon my request.