Aqua Plastic Surgery is not participating with any insurance and the services provided are of cosmetic nature.

Payment is the sole responsibility of the patient and insurance claims will not be filed by Aqua Plastic Surgery. All fees for these procedures and services will be collected prior to the surgical procedure.

It is understood that Aqua Plastic Surgery has classified your procedure as “Cosmetic” and does not accept insurance payments. If you wish to submit a claim for a cosmetic procedure, any potential insurance payments should be made to you as no refunds will be issued post procedure based on an insurance payment. Patients desiring to move forward with any procedures are making this choice voluntarily and not as a clinical recommendation from Aqua Plastic Surgery.


AGREEMENT TO PAY FOR NON-COVERED SERVICES: I {name} understand that my operation is classified as a “Cosmetic” procedure and no insurance is accepted for the performed operation or service. I agree in advance to pay the quoted rate for providing the operation and/or services to me. I understand that Aqua Plastic Surgery will NOT be billing my insurance and that I am responsible for payment in full.