At Art Form Plastic Surgery, we are committed to providing exceptional care and personalized attention to every patient. To ensure the best experience for all patients, we ask that you carefully review and understand the following scheduling, payment, cancellation, and rescheduling policies before booking a consultation, procedure, or surgery.

Your appointment, procedure, or surgery time is reserved specifically for you. We understand that situations may arise that require you to cancel or reschedule. However, when appointments are missed or changed without adequate notice, it affects both our providers and other patients who are waiting for care.

Therefore, fees associated with missed appointments, late cancellations, or rescheduling may be charged to the credit card on file as outlined below. We value your time and appreciate your commitment to your scheduled appointment. We also encourage patients to be certain about their desire for treatment and their ability to meet any associated financial obligations before scheduling services.

If you have any questions regarding these policies, please contact our office at (813) 563-3735.

Office Consultations & Procedure Appointments

All consultation and in-office procedure appointments require:

• Completion of all required patient forms prior to the appointment.
• A valid credit card on file to reserve your appointment.

Consultation Fee

The consultation fee is $100 and is due at the time of scheduling.

Additional fees for treatments, injectables, products, or consumable materials may apply and will be discussed during your appointment.

Appointment Cancellations & Rescheduling

If you need to cancel or reschedule an office appointment, please notify our office as soon as possible by calling (813) 563-3735.

Appointments cancelled or rescheduled with less than 48 hours' notice will incur a $250 cancellation fee, which may be charged to the credit card on file.

Surgical Deposit & Payment Schedule

To reserve your surgical date, a 50% deposit of the surgical fee is required at the time of scheduling.

Additional fees may apply depending on your procedure, including but not limited to:

• Surgical facility fees
• Anesthesia fees
• Laboratory or ancillary service fees

These fees are determined on a case-by-case basis and will be discussed with you prior to surgery whenever possible.

The remaining balance is due no later than two (2) weeks prior to your scheduled surgery date.

Failure to remit the remaining balance by the deadline may result in cancellation of your surgery and forfeiture of your deposit.

Payment Methods & Credit Card Policy

A valid credit card is required to be maintained on file for all consultations, procedures, and surgical scheduling.

Cash payments made in-office are accepted and are our preferred payment method. If you intend to pay by cash, please notify our team at the time of scheduling so we may appropriately note your account.

Payments made by credit card will incur an additional 3% processing fee.

Any applicable cancellation, rescheduling, or no-show fees may be charged to the credit card on file in accordance with the policies outlined in this document.

Surgery Rescheduling Policy

More Than 6 Weeks Before Surgery: One-time rescheduling permitted at no charge.

Less Than 6 Weeks Before Surgery: A $500 rescheduling fee will apply. Additional surgery center, anesthesia, or facility fees may also apply.

Less Than 2 Weeks Before Surgery: Surgery may not be rescheduled.

Multiple Reschedules: Any rescheduling beyond the first occurrence will incur a $500 fee per occurrence, regardless of timing.

Surgery Cancellation Policy

More Than 6 Weeks Before Surgery: Full refund of surgical deposit.

Between 2 and 6 Weeks Before Surgery: Surgical deposit is forfeited.

Less Than 2 Weeks Before Surgery: All fees paid are forfeited.

Refund requests due to documented medical circumstances will be reviewed on a case-by-case basis.

Art Form Plastic Surgery reserves the right to reschedule or cancel a procedure due to medical, safety, or unforeseen circumstances. In such cases, refunds and rescheduling options will be evaluated individually.

Additional Surgical Procedures and Revisions

Every patient heals differently, and many factors may influence the long-term outcome of surgery. While every effort is made to achieve the desired result, additional treatment, revision surgery, or secondary procedures may occasionally be recommended.

Any revision or secondary procedure is elective and will be discussed thoroughly with Dr. Christopher Kieliszak.

The patient remains financially responsible for all costs associated with any subsequent procedures, treatments, or revision surgeries.

Acknowledgment & Agreement

I acknowledge that I have read, understand, and agree to the policies outlined above. I understand my financial responsibilities, cancellation policies, rescheduling policies, and payment obligations associated with my care at Art Form Plastic Surgery.

I also acknowledge that I have received a copy of my surgical quote (if applicable) and have had the opportunity to ask questions regarding these policies.