Lilly Beauty San Francisco

Estimated Cost of Treatment

The estimated cost for your treatment is $____________. Once treatment has begun, changes in the anticipated treatment plan may be required. We will inform you if this occurs and you will be given the option of continuing or changing treatment. ___________ (Patient initials)

Payment Arrangements

As you know, it is this practice’s policy to receive payment prior to the completion of your treatment. If you choose to discontinue care before treatment is complete, you will receive a refund less the cost of care received. You have agreed to pay your patient portion of the treatment fee in the following way:

Payment in full in the amount of $______________
Paid with: ________________________________
Deposit required: $_________________________
Deposit paid with: __________________________
Remaining treatment fee: $___________________

___ equal payments of $_____________________

Getting in Touch

If you have questions about your treatments or the choice of payment options, please do not hesitate to ask. We are here to help you get the quality care you want or need.

We look forward to seeing you at your scheduled appointment at _________ on _________.