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By signing this form, I agree to the following conditions for my participation in La Estetica's Telemedicine service.

A PHP1,500.00 CONSULTATION FEES WILL BE CHARGED ACCORDING TO EXISTING FEE SCHEDULE.

I ACKNOWLEDGE THAT EITHER PARTY (MYSELF OR LA ESTETICA CLINIC) MAY TERMINATE ANY TELEMEDICINE CONSULTATION AT ANY TIME BEFORE OR DURING THE TELEMEDICINE ENCOUNTER AND THAT FEES AND CHARGES MAY BE APPLIED REGARDLESS OF WHETHER THE TELEMEDICINE CONSULTATION IS COMPLETE OR TERMINATED PREMATURELY.

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