Payment & Cancellation Policy
Phone: (210) 640-6310
Fax: (210) 824-2183
It is important that our patients fully understand their financial obligations along with our payment and
cancellation policy prior to undergoing surgery with New Image Plastic Surgery.
I understand that:
● Once my surgery is scheduled with Dr. Homas or Dr. Brostrom, this time is no longer available to
other patients. I agree to submit a $1,000 surgical deposit at the time surgery is scheduled. This
deposit will be applied to the total surgical cost.
● Payment in full is required no later than the date of my pre-operative visit.
Cancellation and Rescheduling Policy:
● We understand that circumstances may arise requiring a cancellation
● Cancellation at least 4 weeks prior to surgery date – Full Refund of Deposit
● Cancellation less than 4 weeks prior to surgery date – Forfeiture of Deposit
We will provide a full refund in the rare circumstance we need to reschedule or cancel your surgery or in
the event of a documented medical reason with a treating doctor's statement.
I UNDERSTAND AND AGREE TO THE ABOVE TERMS
Please sign and return. Thank you.
Signature: __________________________________ Date: ___________________________________
