Elective Surgery Acknowledgement Form

Elective Surgery Acknowledgment Form

Aqua Plastic Surgery Patient Responsibility Policy
We are thrilled you have trusted Aqua Plastic Surgery with your upcoming procedure. Rest assured you are in great hands and will be receiving exceptional care provided by our World Class Surgeons.

While you may have in the past or are currently experiencing symptoms that resulted in you seeking our services, all Aqua Plastic Surgery procedures are Cash Only Services and we do not participate with any insurance plans.

Payment is the sole responsibility of the patient and insurance claims will not be filed by Aqua Plastic Surgery nor will insurance payments be accepted for claims filed by the Patient.
Agreement to Cash Only Services:
I {name} understand that my operation is being performed as a cash only service and no insurance payment will be accepted. I agree in advance to pay the quoted rate for providing the operation and/or services to me prior to my surgery and understand I am waiving the right to submit to my insurance company. I understand that Aqua Plastic Surgery does not issue any refunds for services provided.
Name *

First Name Last Name
Signature *

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DateTime *
Should be Empty:

Elective Surgery Acknowledgment Form