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

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305-861-8266

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Online Plastic Surgery Patient Consultation

Dr. Michael Salzhauer
Bal Harbour Plastic Surgery
1140 Kane Concourse
Bay Harbor Islands, FL 33154
P / (305) 861-8266
F / (305) 356-7909

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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 *

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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Dr. Michael Salzhauer
Bal Harbour Plastic Surgery | 1140 Kane Concourse | Bay Harbor Islands, Florida 33154
P / (305) 861-8266 | F / (305) 356-7909

Breast Augmentation Miami Cirugia Plastica en Espanol

THE PATIENT AND ANY OTHER PERSON RESPONSIBLE FOR PAYMENT HAS A RIGHT TO REFUSE TO PAY, CANCEL PAYMENT, OR BE REIMBURSED FOR PAYMENT FOR ANY OTHER SERVICE, EXAMINATION, OR TREATMENT THAT IS PERFORMED AS A RESULT OF AND WITHIN 72 HOURS OF RESPONDING TO THE ADVERTISEMENT FOR THE FREE, DISCOUNTED FEE, OR REDUCED FEE SERVICE, EXAMINATION, OR TREATMENT.