Michael Salzhauer Bal Harbour Plastic Surgeon, Cosmetic Face Lift, Botox, Breast Implants, Augmentation & Enhancement, Eyelid Surgery Miami

Contact Bal Harbour Surgery in Miami to schedule a consultation with our board-certified plastic surgeon Dr. Michael Salzhauer.

Dr. Michael Salzhauer
Bal Harbour Plastic Surgery
9801 Collins Avenue, Suite L1
Bal Harbour, Florida 33154
P / (305) 861-8266
F / (305) 866-5052

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Please fill out and submit the application below. One of our Patient Coordinators will contact you shortly to discuss your financing options, or for immediate assistance call 305-861-8266.

**ALL Applicant and Employer Information must be filled out completely in order to be processed.

Loan Information
Total Amount of Loan	What procedures would you like to finance?
$

Applicant Information
First Name	Last Name

Middle Name	Mothers Maiden Name

Social Security #	Date of Birth (month, day, year)
- -	- -
Email Address	Check the box if no email
	Check the box if no email
Current Address	Time at Current Address
	years months
City	State Zip

Housing	Monthly Rent/Mortgage

Home Phone	Alternate Phone
- -	- -

Complete below if applicant has moved in the last 2 years
Previous Home Address	Time at Previous Address
	years months
City	State Zip

Employer Information
Employer Name	Position

Income	Payment Schedule

Employer Address	Time at Current Employer
	years months
City	State Zip

Business Phone
- -
Other Income	Source of other income

Complete below if applicant has changed jobs in the last 2 years
Previous Employer	Position

Previous Employer Address	Time at Previous Employer
	years months
City	State Zip

Co-Applicant Information (Not Required)
First Name	Last Name

Middle Name	Relationship to Applicant

Social Security #	Date of Birth (month, day, year)
- -	- -
Current Address	Time at Current Address
	years months
City	State Zip

Housing	Monthly Rent/Mortgage

Estimated Property Value	Current Mortgage Balance

Home Phone	Alternate Phone
- -	- -
Driver's License State	Driver's License #

Complete below if Co-applicant has moved in the last 2 years
Previous Home Address	Time at Previous Address
	years months
City	State Zip

AUTHORIZATION TO RELEASE CREDIT INFORMATION AND POLICIES
By my signature, I authorize "Bal Harbour Plastic Surgery" to submit to a loan processing company to run a credit report and verify the information I have provided. I understand "Bal Harbour Plastic Surgery" will be acting as my credit-processing agent and therefore does not approve, deny, set the rate and terms, guarantee loan approvals or discriminate against anyone for any reason. As a part of this search, I fully understand my credit request may be presented to multiple credit issuing companies and/or search companies including (but not limited to) Banks, Finance Companies, Credit Card Issuers, and partnership programs with other such affiliated companies. I understand that I will be charged loan processing fees for these services. Furthermore, while calculated monthly, I understand that the total amount of the fees will be added to my base loan amount requested and become a part of my principal balance in most cases. I agree to "hold harmless" "Bal Harbour Plastic Surgery" from any and all legal actions that might be taken as a result of a disputed matter with my Service Provider or Vendor.
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