Forms
 
Patient Registration & Consent Form
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PDF Form
Registration form required for all patients who plan on undergoing surgery
Pre-op Checklist
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PDF Form
Contains a checklist detailing what must be done prior to undergoing surgery.
Surgery Patient Policies
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PDF Form
Policies applying to all patients undergoing surgery.
Touches on general requirements, surgery methods, and policies related to surgery costs, payment, and financing options.
Financial Policy
1. Preliminary Consulation Fee: $100 to be paid at time of service.
  Includes secondary consultation within 60 days, if needed
 
2. Estimate of operation fees provided as part of consultation
  Estimate does not factor potential costs from Physical Examination(s), Blood Tests, & Prescriptions
 
3. 10% security deposit must be paid at time of scheduling for surgery. The remaining balance will be due 3 weeks prior to surgery.
   
4.

Cancellation Refund Policy:

 
Refund Amount Cancellation Window
100% 3 weeks prior to operation
25% 14-20 days prior to operation
No more than 50% If rescheduled then cancelled
   
5. Post-Op visits relating to original surgery are covered for up to one (1) year.
  Unrelated consultations billed at reduced rate of $65
   
6. A reduced surgeon's fee will be assessed for minor re-operations, performed within twelve (12) months of original surgery
  Fees for Operating Room Faclilty, Anesthesia, and Supplies are not covered (Minimum Charge: $1,650)
   
7.

$30.00 Returned Check fee

   
8. $50.00 Fee assessed for missed consultation appointments if not cancelled within 48 hours.
   


 
 
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