Patient Information

Full Name

Birth Date

Phone Number

Address

Email Address

Date of service

Policy Information: Terms and Conditions

By checking the box you are agreeing that you are aware that you are giving up the right to sue in exchange for strict liability and the rapid recovery of specified benefits through CoverWell by InjectSure for possible complication(s) from your purchased Med Spa and/or Wellness Services, and you have authorized to have the above-selected amount withdrawn from the specified payment account. If you do not authorize this payment or agree to these terms, do not check the box.

Your CoverWell Premium

$0 - $1,000 - $60.00 $1,001 - $2,000 - $120.00 $2,001 - $3,000 - $180.00 $3,001 - $5,000 - $200.00

By submitting this application, you the Client provide your consent to be contacted by CoverWell by InjectSure by phone and email regarding your policy, as well as any necessary future communication. This is a waiver by the Client of the HIPAA authorization requirement for Medical Spa & Wellness Service Providers.

What Med/Spa Management Software are you currently using?

Signature of Client (By typing your name below you are signing this document to certify it is true and correct to the best of your knowledge)

Patient Information

Contact Us for a Complimentary Consultation

Copyright Coverwell by Injectsure 2023 | Website Design by True North Social

Privacy Policy