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The following forms can be downloaded to your computer and printed at home. By filling out these forms ahead of time you will save significant time at the time of your visit. If you have any questions when filling out these forms, please do the best you can, our staff will assist you with your questions on the day of your visit.
 Note: You will need Adobe Acrobat Reader to view these files. To download Adobe Acrobat Reader, click on the icon at right.
Please print out and complete the following two forms:
Read Iowa Plastic Surgery's Notice of Privacy Practices:
Please read the following sheet(s) if you have had or will have any of the following procedures:
We offer referrals to the finance programs detailed below
VISA, Mastercard and American Express are accepted by Iowa Plastic Surgery.
  
Wells Fargo Bank – A national bank chain with a local branch that offers many variations of consumer loans. They offer quick responses with flexible payment terms.
Contact: Amy Crist
Phone: 563.328.8366
The National Bank – A local bank that offers many variations of consumer loans. They offer quick responses with flexible payment terms.
Contact: Gregory A. Jipp, Assistant Vice President, Consumer Loan Officer
2040 1st Ave.
Moline, IL 61265
Phone: 309.277.2265
Fax: 309.764.1216
Email: gjipp@thenb.com
CareCredit- It is a flexible patient/client payment program, specifically designed for healthcare expenses, which make it easier for you to get the treatment or procedures you want and need.
Phone: 1.800.365.8295
Website:www.carecredit.com
Health One Financing- At Health One, the customers select the financing program that is best for them, and a program that will make his or her procedure the most affordable.
Phone: 1.888.748.3621
Website: www.HealthOne-Financial.com
We recommend that you call all programs to compare interest rates.
Phone 563.322.8877
4334 53rd Street
Davenport, IA 52807
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