Wilshire Aesthetics

Forms and Policies

If you are visiting us for the first time, you'll need to review and complete each of these forms.  Feel free to print them out and complete them prior to your visit.  Click here to download and complete all the registration forms at once.  Or, you can download each individual form below.  Thanks!

CareCredit

0% interest loans for all cosmetic procedures are available for a limited time period from CareCredit®, a GE Money Company.

New Patient Registration Form

Collects your name, contact information, and other important data.

Financial-Billing Policy When We are In Your PPO's Network

Our billing policy is simple and easy.

Financial-Billing Policy When We are NOT in Your Provider's Network

Our billing policy is easy and straight-forward.

Consent Form

In order to keep medical expenses as low as possible, it is our policy to use "arbitration" rather than litigation when settling disagreements.

Credit Card Authorization Form

For your convenience, we will bill your insurance carrier [ except for HMO Plans ]. If your insurance carrier refuses to pay for your treatment, we will charge the outstanding amount to your credit card. We understand that some people prefer not to provide their credit card. For those patients, it is necessary for you to be considered a "cash patient" and pay for your medical treatment when you receive it.

Patient Bill of Rights

We're dedicated to providing the best care possible and we've documented our commitment.

Privacy Policy

We are passionate about protecting your privacy.

No-Show Policy

When you make an appointment, we take it seriously.
  
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