Free Cosmetic Surgery Payment Plan Template

Cosmetic Surgery Payment Plan

This payment plan outlines the terms and conditions for the cosmetic surgery services provided by [YOUR COMPANY NAME]. It serves to ensure clear communication regarding the payment process and financial expectations. The patient, hereafter referred to as "the Client," agrees to the terms outlined in this agreement.

1. Patient Information

  • Full Name: Erica Hill

  • Age: 33

  • Contact Information: 222 555 7777

  • Address: Durham, NC 27701

2. Procedure Information

  • Surgery Type: Facelift and Eyelid Surgery

  • Surgery Date: June 15, 2071

  • Surgeon: Dr. Lance Nader, MD

  • Procedure Cost: $12,500

3. Payment Schedule

The total cost for the procedure is $12,500, and the payment will be divided into the following installments:

  • Deposit Due at Time of Scheduling: $2,500 (non-refundable, due upon booking)

  • First Installment: $3,000 (Due by May 15, 2071)

  • Second Installment: $3,000 (Due by June 1, 2071)

  • Final Payment: $4,000 (Due by June 14, 2071)

4. Payment Methods

The Client may choose from the following payment methods:

  • Credit Card: Visa, MasterCard, American Express, Discover

  • Debit Card

  • Bank Transfer

  • Personal Check

  • Financing (if applicable): CareCredit Financing Option

5. Late Payments

  • Late Payment Penalty: A fee of $100 will be applied for any payments not received within 10 days of the due date.

  • Non-payment: Failure to make payment within 30 days of the final due date may result in the cancellation of the procedure, with no refund of payments made.

6. Insurance & Other Payment Considerations

  • Insurance Coverage: This procedure is not covered by the patient’s insurance. The patient is responsible for paying the full cost.

  • Financing Options: If the patient opts for financing, they must submit their application for approval by CareCredit before proceeding with the surgery.

  • Refunds: Refunds are subject to [YOUR COMPANY NAME] refund policy. If the surgery is canceled by the client more than 30 days before the scheduled surgery date, a partial refund may be issued, minus any non-refundable fees.

7. Acknowledgment and Agreement

By signing below, the patient acknowledges and agrees to the terms and conditions outlined in this payment plan. The patient also acknowledges that they have reviewed the payment schedule, understand the total cost of the procedure, and agree to the payment structure.

Client Name: Erica Hill

Date: March 15, 2071

8. Office Use Only

  • Surgery Date Confirmed: March 16, 2071

  • Payment Plan Created By: [YOUR NAME]

  • Date of Plan Finalized: March 16, 2071

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