Patient Forms

New patients will need to fill out patient information, patient history and insurance forms. We have included these standard forms below. Please print and fill out each form prior to coming in. You will need Adobe® Acrobat® Reader™ -- a plugin is available from Adobe.

• New Patient Cosmetic Consultation Forms
• Laser Medical History Form
• Artic Peel Consent
• Arctic Peel Pre Post Instructions
• Laser Hair Reduction Consent
• Laser Hair Removal Pre Post Instructions
• Laser Vein Treatment Consent
• Laser Vein Treatment Pre Post Instructions

Patient Financing

As you consider cosmetic surgery you may be wondering about your payment options. There are a number of payment options. We offer an array of programs designed to meet your individual needs.

For financial assistance, call Jenny at (888) 455-FACE  or email her at, jroach@PICosmeticSurgery.com   Jenny has worked with Premier Image Cosmetic & Laser Surgery for over 10 years. She's helped many patients achieve their dreams with payment plans that fit comfortably in their budgets.

Types of Payments

• Cash or Check: Personal check, cashier's check, or cash.
• Credit Cards:Visa, MasterCard, Discover, or American Express.

 Patient Payment Plans:

We offer a number of patient financing options. Call and speak with our financial counselor, Jenny. You want to be sure you are applying to the company that will best meet your individual needs. Jenny can guide you in choosing the best options and help you with the pre-screening process that will not affect your credit.

We offer No Interest (same as cash) payment plans for up to 12 months. We also offer extended payment plans for 24, 36, 48 or 60 months with varying rates of interest depending upon your credit history.

CareCredit gives you the freedom to get your plastic surgery procedure whenever you're ready. It's easy to apply. With three simple steps, including an instant approval process, you can say goodbye to the waiting time and reward yourself sooner. CareCredit offers interest-free loan options starting as low as $300 for 3, 6, or 12 months to qualified applicants. They have payment plans available for 24, 36, 48 and 60 months. They offer up to $25,000 in financing. * From above: Based on qualifying Care Credit loan for $5000 - 60 month payment plan at 11.9%. Apply on line:  www.carecredit.com/apply/index.html

Capital One makes it easy to afford the reconstructive or cosmetic surgery that you need or want. Use Capital One® Healthcare Finance to pay for procedures, from $750 to $25,000. Capital One offers installment loans with low, fixed rates from 1.99% APR to 25.99% APR*, from 18-60 month extended payments plan. Either way, you'll be able to find an option designed to fit within your budget. You'll like their flexible payment options—we can set up a payment schedule for you, from 18 months to five years. Capital One Healthcare Finance helps make high quality cosmetic procedures—and your new look— a reality. Apply online www.capitalonehealthcarefinance.com/cosmetic/

Chase Healthcare Financingis now ChaseHealthAdvance financing optionsSM. Now you can get easy access to flexible financing for all your healthcare needs, including cosmetic surgery. Choose from no interest plans of 3, 6, 12, 18 and months or choose an extended payment plan for up to 60 months. Please refer us by completing this form and we’ll take it from there.

 Patient Links

Click here for Cosmetic Dentistry