Patient Referral
Please fill out the form below. Our Freedom+ team will find you a provider closest to you.
Please fill out the form below. Our Freedom+ team will find you a provider closest to you.
The undersigned principal(s) certify that he/she has full authority to act on behalf of the applicant. The applicant (if a sole proprietor), principals, and guarantors each certifythat all of the information contained in this application and on each document required to be submitted in connection herewith are true and complete.
The applicant (if a sole proprietor) and each guarantor hereby authorize photobiotech and its Assigns to obtain his/her credit profile from the national credit bureau(s) for the purpose of considering this credit application and any subsequent update, renewal, collection or additional credit.
A photocopy or facsimile of this authorization shall be as valid as the original. Further, the applicant and guarantors hereby authorize each bank and finance reference listed in this credit application to release information about the applicants and guarantors to photobiotech and its Assigns, as requested by photobiotech.
If your application for business credit is denied you have the right to a written statement of the specific reasons for the denial by writing to photobiotech, within sixty (60) days from the date you are notified of our decision. photobiotech will send you a written statement of the reasons for the denial within thirty (30) days of receiving your request for the statement.
The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, or age (provided the applicant has the capacity to enter into a binding contract); or because all or part of the applicant’s income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act.
By signing below, I also wish to continue to receive updates from photobiotech regarding our account. Information should be sent to the fax and/or e-mail address provided for this account.
We are committed to maintaining the accuracy, confidentiality, and security of your personally identifiable information (“Personal Information”). As part of this commitment, our privacy policy governs our actions as they relate to the collection, use and disclosure of Personal Information.
1. Introduction
We are responsible for maintaining and protecting the Personal Information under our control. We have designated an individual or individuals who is/are responsible for compliance with our privacy policy.
2. Identifying Purposes
We collect, use and disclose Personal Information to provide you with the product or service you have requested and to offer you additional products and services we believe you might be interested in. The purposes for which we collect Personal Information will be identified before or at the time we collect the information. In certain circumstances, the purposes for which information is collected may be clear, and consent may be implied, such as where your name, address and payment information are provided as part of the order process.
3. Consent
Knowledge and consent are required for the collection, use or disclosure of Personal Information except where required or permitted by law. Providing us with your Personal Information is always your choice. However, your decision not to provide certain information may limit our ability to provide you with our products or services. We will not require you to consent to the collection, use, or disclosure of information as a condition to the supply of a product or service, except as required to be able to supply the product or service.
4. Limiting Collection
The Personal Information collected will be limited to those details necessary for the purposes identified by us. With your consent, we may collect Personal Information from you in person, over the telephone or by corresponding with you via mail, facsimile, or the Internet.
5. Limiting Use, Disclosure and Retention
Personal Information may only be used or disclosed for the purpose for which it was collected unless you have otherwise consented, or when it is required or permitted by law. Personal Information will only be retained for the period of time required to fulfill the purpose for which we collected it or as may be required by law. [If applicable, include a description of any parties with whom you may share Personal Information.]
6. Accuracy
Personal Information will be maintained in as accurate, complete and up-to-date form as is necessary to fulfill the purposes for which it is to be used.
7. Safeguarding Customer Information
Personal Information will be protected by security safeguards that are appropriate to the sensitivity level of the information. We take all reasonable precautions to protect your Personal Information from any loss or unauthorized use, access or disclosure.
8. Openness
We will make information available to you about our policies and practices with respect to the management of your Personal Information.
9. Customer Access
Upon request, you will be informed of the existence, use and disclosure of your Personal Information, and will be given access to it. You may verify the accuracy and completeness of your Personal Information, and may request that it be amended, if appropriate. However, in certain circumstances permitted by law, we will not disclose certain information to you. For example, we may not disclose information relating to you if other individuals are referenced or if there are legal, security or commercial proprietary restrictions.
10. Handling Customer Complaints and Suggestions
You may direct any questions or enquiries with respect to our privacy policy or our practices by contacting: privacy@discountlasers.com.
11.Additional Information
Cookies
A cookie is a small computer file or piece of information that may be stored in your computer’s hard drive when you visit our websites. We may use cookies to improve our website’s functionality and, in some cases, to provide visitors with a customized online experience.
Cookies are widely used and most web browsers are configured initially to accept cookies automatically. You may change your Internet browser settings to prevent your computer from accepting cookies or to notify you when you receive a cookie so that you may decline its acceptance. Please note, however, if you disable cookies, you may not experience optimal performance of our website.
Other Websites
Our website may contain links to other third-party sites that are not governed by this privacy policy. Although we endeavour to only link to sites with high privacy standards, our privacy policy will no longer apply once you leave our website. Additionally, we are not responsible for the privacy practices employed by third party websites. Therefore, we suggest that you examine the privacy statements of those sites to learn how your information may be collected, used, shared and disclosed.
Thank you for your inquiry.
A Freedom+ adviser will contact you as soon as possible.
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