Cancellation Policy Form

For more immediate scheduling assistance please call our office during operating hours all scheduling is done by phone.
Reston: 703-481-0002
| Chevy Chase: 301-222-2020

At The Naderi Center for Plastic Surgery & Dermatology we make every effort to satisfy the needs of our patients. Scheduling surgery and organizing the related administrative processes requires a significant amount of coordination and time by our surgeons, staff, surgical facilities, anesthesiologists, and associated personnel. Your surgery date is reserved exclusively for you. Any changes made to your surgery date affects all coordinating parties as well as other patients. Accordingly, we require a 20% non-refundable deposit of the surgeon’s fee to reserve a surgery date and start the scheduling process. The balance of the surgeon’s fee will be due no later than 30 days prior to the surgery date.

Name(Required)

Email(Required)

Date of Birth(Required)

Zip code(Required)

RESCHEDULING & CANCELLATION FEES

We understand that situations may arise that will require you to cancel or reschedule your surgery date. If you need to reschedule your surgery date, we will do our best to select a new date for you.

Rescheduling Fee. If you reschedule your surgery date at any time, an additional non-refundable $750.00 administrative rescheduling fee will be collected at the time of each rescheduling. This non-refundable rescheduling fee does not apply towards the surgeon’s fee and is in addition to any other fees. If your surgery date is rescheduled by our staff, surgeons, or another physician for medical reasons related to your pre-surgical testing, you may not be charged this fee.

Patient (or legal guardian) Initial:(Required)

Cancellation Fee (30 Days or More). If you cancel your surgery 30 days or more prior to your surgery date, you may receive a refund of the paid surgeon’s fee (minus the 20% non-refundable deposit and any administrative rescheduling fees).

Patient (or legal guardian) Initial:(Required)

Cancellation Fee (Less Than 30 Days). If you cancel your surgery less than 30 days from your surgery date, you may be refunded 50% of the paid surgeon’s fee. You will not be entitled to a refund of the 20% non-refundable deposit or any non-refundable rescheduling fees.

Patient (or legal guardian) Initial:(Required)

By signing below, you agree to The Naderi Center’s Surgery Scheduling, Rescheduling & Cancellation Policy. You also agree that you will not initiate a “charge back” on the credit card you use to schedule your surgery. For your safety and protection all credit card payments for surgery balances must be made in person. Please note that a 3% non-refundable credit card processing fee will be applied to surgery payments paid with credit card.

Patient (or legal guardian) Print(Required)

Patient (or legal guardian) Sign(Required)

Date(Required)

Name

This field is for validation purposes and should be left unchanged.