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





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.
Please Print Your Name
    I agree

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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.