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STARS Educational Program Form
Credit Estimation Form
5
Questions
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HIPAA
Compliance
1
Name
First Name
Last Name
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2
Planned Procedure
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3
Total Professional Fee
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4
Educational Media Segments
*
This field is required.
Video/Audio/Photo elements that are a part of your cosmetic journey.
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My Bag
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My Bag
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Great Product Name
$20
Quantity:
1
Size:
Small
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Great Product Name
$20
Quantity:
1
Size:
Small
Remove
Edit
Great Product Name
$20
Quantity:
1
Size:
Small
Remove
Edit
Great Product Name
$20
Quantity:
1
Size:
Small
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ORDER SUMMARY
Total procedure credits
USD
Consultation
Initial cosmetic consultation and pre-/post-consultation interviews. Simulation possible.
$
100.00
+
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Pre-operative Visit
Pre-operative visit and pre-/post-visit interviews
$
50.00
+
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Day of Surgery
Day of Surgery visit and pre-surgery interview.
$
200.00
+
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First Follow up Visit
First follow up visit (~ 1-2 weeks) and pre/post-visit interview.
$
100.00
+
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Second Follow up Visit
Second follow up visit (~3 weeks) and pre/post-visit interview.
$
100.00
+
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Third Follow up Visit
Third follow up visit (~3 month) and pre/post-visit interview.
$
100.00
+
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Fourth Follow up Visit
Fourth follow up visit (6m) and pre/post-visit interview.
$
100.00
+
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Written Experience
A written paragraph of overall experience.
$
100.00
+
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Video Testimonial
A video summary of a positive surgical experience
$
200.00
+
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5
Signature
I understand that STARS Plastic Surgery will apply the above credits towards the cost of my upcoming procedure. I will pay back these credits once I have fulfilled the above tasks satisfactorily. If the tasks are not satisfactorily completed or I decide to not perform these tasks, I understand that I will be responsible for for any balance owed.
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