Thank you for choosing my office for your cosmetic procedure. The staff and I are committed to your treatment being
successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our financial policy that we require you to read and sign prior to any type of reatment. All patients must complete our patient information.
We require a 20% non-refundable deposit of the surgeon’s fee to guarantee your surgery date and time. Surgeries cancelled within 72 hours of scheduled surgery date will be subject to a 20% surgeon’s fee.
Payment for all cosmetic surgical procedure is due in full prior to surgery. We gladly accept personal check, cash, Visa, Master Card, American Express & Discover. A $25.00 return check charge will apply to all returned checks. We do not accept postdated checks and will not hold checks.
We offer financing with Care Credit
Follow up Visits & Surgery Revisions
After 6 months there is a $75.00 follow up charge for all office visits. All revision or touches up surgeries are subject to hospital, anesthesia and surgeon’s fee.
Postage = $4.95 Billing Records = $25.00 Each additional page = $0.50 Medical Leave Forms = $50.00 Medical Records (1st 20 pages) = $25.00
I have read and understand the above information regarding payment, follow up visits, surgery revisions and other fees.
Patient Registration (Cosmetic)
Acknowledgement of Review of
Notice of Privacy Practices