Lakewood (216) 227-3333
Middleburg Heights (440) 845-8290
Office Hours: Monday – Friday 8am – 5pm
By Appointment Only
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To give our patients the best care possible, it is important to help us maintain our records and
keep our accounts current.
For elective cosmetic surgical procedures, we require a deposit of one-half (½) of the total fees to be paid at the time you schedule your surgery. The balance of the fees must be paid in full at the time of your pre-surgical consultation, which is scheduled two weeks prior to your surgery. >
Cleveland Cosmetic Surgery does not accept insurance of any type as payment for surgical procedures. You are personally responsible for payment for your elective cosmetic surgery.
For your convenience, we gladly accept MasterCard, Visa, American Express and Discover for payment. If you choose to pay by credit card, there will be a 3.5% convenience fee added to the amount of your charge. The convenience fee is not refundable under any circumstances. We will only accept personal checks up to 21 days prior to your scheduled surgery date. There will be a $50.00 fee for all checks returned to us. All delinquent accounts will be referred to collections and you will be responsible for additional fees.
Cleveland Cosmetic Surgery also has relationships with third party credit lenders such as Care Credit to assist you with payment options. Please ask for details.
Your appointment time is reserved exclusively for you and we have scheduled medical staff to be available for your appointment time and location. We know your time is valuable, so please remember ours is too. If you must cancel a surgery date with less than 21 days notice, you will lose 50% of your proposed treatment plan and will also be charged an additional $500.00 fee
for the cancelled anesthesia team. These cancellation fees are allocated for administrative, facility and medical purposes. Additionally, there will be no cash refunds for the balance of the fee, however, any credit balance may be used for future surgical procedures or purchase of
I hereby request and authorize the release of all information, without limitations regarding
any physical and mental condition, as revealed by your observation or treatment, past, present
This includes medical, surgical and dental history, x-ray findings, diagnosis, prognosis and
access to all hospital records and photocopies of the same.
Cleveland Cosmetic Surgery is required to provide you with a copy of the Notice of Privacy Practices,
which states how we may use and/or disclose your health information. Please sign this Form to
acknowledge receipt of the Notice. You may refuse to sign this acknowledgment if you wish.
Additional information requested:
14700 Detroit Ave Lakewood, OH 44107
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