Common Contracts
2 similar Fee Agreement contracts
N I C H T E R /H O R O W I T ZFee Agreement • September 5th, 2023
N I C H T E R /H O R O W I T ZFee Agreement • November 22nd, 2011
FEE AGREEMENT F Patient Name: DOB: Please initial each clause and sign below to indicate you have read and understand the fee agreement. Pacific Center for Plastic Surgery requires all medical services to be paid in advance. A $500.00 administration fee is required at the time of scheduling for all surgical procedures. This fee is applied towards your surgery. The remaining surgery balance must be paid in full at the pre-op or the pre-op appointment will be rescheduled. If the pre-op appointment is rescheduled, the surgery date may have to be rescheduled also. Surgery cancellations require notice to our office in writing. If the cancellation request is after the pre-op appointment and prescriptions have been issued, no refunds will be made until the prescriptions are returned to the office. We will not reimburse prescription fees if prescriptions have been filled. If surgery is cancelled, the administration fee will be retained by the Pacific Center for Plastic Surgery. The work o
