Financial Policy Form Δ Please review the financial policies below. If you have any questions regarding these policies, please feel free to ask. 1. Payment Policy All fees for consultations, procedures, and treatments are due at the time services are rendered unless prior arrangements have been made. Cosmetic procedures are not typically covered by insurance and are the patient’s responsibility. Consultation fees: Due at time of visit Surgical procedures: Require deposit to secure scheduling Remaining balance: Due prior to procedure date We accept: Cash, credit/debit cards, and approved financing plans. 2. Deposits & Scheduling A non-refundable deposit is required to reserve your surgical date. Deposits will be applied toward the total cost of the procedure Surgery dates are not guaranteed until deposit is received Failure to pay remaining balance by the due date may result in cancellation 3. Cancellation & Rescheduling Policy We understand that schedules may change; however: Cancellations or rescheduling requests must be made at least 14 days in advance Deposits may be forfeited for late cancellations or no-shows Additional fees may apply to reschedule surgery 4. Refund Policy Fees for services already rendered are non-refundable Surgical fees are generally non-refundable once the procedure has been performed If a procedure is canceled within the allowed timeframe, refunds may be issued minus administrative fees 5. Insurance (If Applicable) If any portion of your procedure is deemed medically necessary: We may assist with insurance submission; however, coverage is not guaranteed Any denied claims become the patient’s responsibility Co-pays, deductibles, and uncovered services must be paid by the patient 6. Acknowledgment & Consent By signing below, I acknowledge that: I have read and understand the financial policies outlined above I agree to be financially responsible for all services rendered I understand that results are not guaranteed and fees are not contingent on outcome Patient Signature(Required)Email(Required) Date(Required) MM slash DD slash YYYY Printed Name(Required)Witness/Staff Signature(Required)Date(Required) MM slash DD slash YYYY Privacy Notice We comply with Federal law, which requires us to maintain the privacy of protected health information, and to provide patients with notice of our legal duties and privacy practices with respect to protected health information.Please list below those individuals with whom we may share your health care information.If you have any questions, please speak with our HIPAA Compliance Officer in person or by phone at our main phone number. I have received a copy of this privacy notice and I both understand and agree to the terms.Patient Name (print)(Required)Date(Required) MM slash DD slash YYYY Patient/Guardian Signature(Required)CAPTCHA
