Surgery Scheduling Fee

This surgery proposal is subject to the following terms and conditions:

By initiating payment, I acknowledge and understand the terms of this surgery proposal for services from Emily Borsting MD (Borsting LLC).I understand this is solely an estimate of cost and in no way guarantees the financial liability of the guarantor after insurances have paid. I understand that a $1,000.00 non-refundable deposit is required to schedule surgery, and will be applied to the surgeon fee. Surgeon fees will be valid for 6 months from payment of the scheduling fee. I understand that full payment of all cosmetic totals are due two weeks prior to surgery. Typically, the pre-operative appointment is scheduled at that time. I understand that the above estimated cost includes insurance benefits as provided to us by my insurance provider. I understand that I am responsible for all charges whether or not they’re covered by insurance. I understand the patient portion may change if changes are made to the treatment plan or if insurance pays more or less than the estimate. I understand that actual costs can change based on the date of service. I understand that insurance provider “coverage” does not necessarily translate to full payment of treatment cost. Please contact your insurance carrier/s for confirmation of cost and coverage.