Aesthetic Injectable Treatment Billing Agreement
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Aesthetic Injectable Treatment Billing Agreement
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This specialized billing agreement is designed for medical spas, dermatology practices, and plastic surgery centers offering cosmetic injectable treatments. The form clearly outlines pricing for various injectable products and treatment areas, distinguishes between per-unit and per-syringe pricing models, and documents package deals or membership programs. It covers payment collection timing, accepted payment methods, and policies for deposits, cancellations, and no-shows specific to scheduled aesthetic appointments.
The template protects practices financially while setting clear patient expectations for elective cosmetic procedures not covered by insurance. It includes sections for touch-up policies, product guarantee limitations, treatment series agreements, and consent for pre-payment of multi-session packages. The form addresses specific billing scenarios common in aesthetic medicine such as volume discounts, loyalty programs, seasonal promotions, and the non-refundable nature of opened injectable products, ensuring both provider and patient understand the financial commitment before treatment.
What's included
- Injectable product pricing
- Per-unit or per-syringe costs
- Treatment area itemization
- Package deal options
- Deposit and payment timing
- Cancellation policy terms
- Touch-up protocol and costs
- Membership program details
- Payment method authorization
- Financial responsibility acknowledgment
Who uses this template
- Medical spas
- Dermatology aesthetic practices
- Plastic surgery offices
- Cosmetic injection clinics
- Anti-aging medicine centers
All form fields
9 fields across 2 pages. Customize any field after signing up.
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