Putting You First
Patient Resources
As a patient of Polyclinic Plastic Surgery, expect a smooth process and a helping hand. We pride ourselves in being there when you need us and always putting you first. On this page, you’ll find a few resources to help you prior to, or after, your appointment with us.
Patient Forms
Insurance & Financing
Rewards Program
Reconstruction Support Group
Hours & Directions
Patient Forms
Aesthetic Patient Intake Form
Click the button below to download the Aesthetic Patient Intake Form. (Note: your browser settings will open the form in a new tab or prompt you to download)
Patient Health History Form
Click the button below to download the Patient Health History Form. (Note: your browser settings will open the form in a new tab or prompt you to download)
Pre-Anesthesia Assessment Form
Click the button below to download the Pre-Aesthetic Assessment Form. (Note: your browser settings will open the form in a new tab or prompt you to download)
Affordable & Easy
Insurance Coverage & Financing
Understanding Your Health Plan
We encourage all patients to check with your health insurance company before making an appointment to learn about your insurance coverage, co-pay requirements and provider networks. (Be sure to note which physicians, clinics and hospitals are included in your provider network.)
Insurance can change throughout the year. Please verify that your Polyclinic physician is a participating provider with your insurance to ensure access and coverage.
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At the Polyclinic Plastic Surgery Center, all of our cosmetic patients have CosmetAssure coverage for their procedure. Coverage varies by procedure and will be discussed during your consultation. Every surgery, including elective cosmetic surgery, carries the risk of a complication. CosmetAssure was created in 2003 by board certified plastic surgeons because most major health insurance policies excluded payment for treatment of a complication from an elective cosmetic surgery.
As the number of elective cosmetic procedures increase, so does the number of medical complications arising from these procedures. CosmetAssure is an affordable solution to the lack of insurance coverage for medical complications that can occur during or after surgery. CosmetAssure provides peace of mind to both board certified surgeons and patients in the unlikely event a complication were to occur. Surgeons can execute the best medical care knowing the patient will not suffer a financial loss due to post surgical medical bills.
Covered Procedures
As the pioneer in complications insurance, CosmetAssure provides coverage to patients undergoing a variety of elective cosmetic procedures.
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Coverage Requirements
CosmetAssure covers patients during the 45 days immediately following their surgery with a board certified surgeon. In the event of a complication, treatment at an accredited facility will be covered up to the maximum limits of the policy.
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CareCredit make it easy to pay your bill in a few minutes, while taking advantage of promotional financing options. Here, you’ll be able to turn a single bill from your doctor into a series of convenient monthly payments you can pay over time. It’s here to help you better manage your healthcare expenses. Payment can be made online after you leave from your consult.
Save on Aesthetic Treatments
Rewards Program
The Polyclinic participates in the Brilliant Distinctions program . To participate, sign up online or ask a member of our staff for more information.
EARN POINTS
With every participating treatment or product purchase
REDEEM
$10 for every 100 points
SAVE
On future treatments or products
Organizing support when you need it most
Breast Reconstruction Support Group
Meetings provide an opportunity to discuss:
- Surgical options for reconstruction and questions to ask plastic surgeons
- Tips on preparing for surgery
- Insight on what to expect following surgery
- The emotional impact of a cancer diagnosis and feelings that arise while considering reconstructive surgery
