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Financial Agreement for Cosmetic Procedures.docx

Financial Agreement for Cosmetic Procedures.docx 2025

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The document is a financial agreement for cosmetic procedures at a medical office in Englewood Cliffs, NJ. It outlines the patient's financial responsibility for the full cost of the procedures, the non-billing of insurance, rescheduling policies, and acknowledges that results may not meet expectations. The document includes sections for procedure details, payment schedules, and signatures from both the responsible party and physician.

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Click ‘Get Form’ to open the Financial Agreement for Cosmetic Procedures in the editor.
Begin by entering today’s date and the procedure date(s) at the top of the form. This ensures that all parties are aware of the timeline.
In the section where you state your name and date of birth, fill in your personal information accurately. This is crucial for identification purposes.
Review the financial responsibilities outlined in the agreement. Make sure you understand that you are responsible for all costs associated with the procedures listed.
Fill out the review of procedure(s) and payment schedule section. List each procedure along with its fee, ensuring to initial next to each entry as required.
Complete any additional fields regarding deposits and signatures at the bottom of the form, including your signature and date, as well as that of your physician.

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2016	4.6 Satisfied (23 Votes)

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