Patient Information

Iowa Plastic Surgery


Patient Forms

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.

Please print out and complete the following forms:


Read Iowa Plastic Surgery's Notice of Privacy Practices:

 

Procedure Information Sheets

Please read the following sheet(s) if you have had or will have any of the following procedures:



Abobe Reader Please note: The documents above are in Adobe® PDF format. They require Adobe Reader to be viewed. If you do not have Adobe Reader, you can download it for free by clicking here.

 

Payment Methods & Financing Options

VISA, MasterCard, American Express and Discover


Iowa Plastic Surgery offers referrals to the finance programs detailed below:

Advance Care Card - Leading provider of patient financing for elective procedures offering patients an affordable financing option.
Phone: 1.800.432.9470
Website: www.advancecarecard.com


CareCredit - Is a patient payment program, specifically designed for healthcare expenses, which makes 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 their procedure the most affordable.
Phone: 1.888.748.3621
Website: www.HealthOne-Financial.com

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
Davenport, IA 52807
Phone:  563.328.8366

Quad City Bank & Trust – A flexible local bank that offers flexible payment plans, coupled with many types of consumer loans. They offer quick responses with comparable rates.

Contact: Vicky Brogan, Private Banking Officer
2118 Middle Road
Bettendorf, IA 52722
Phone: 563.344.0600
Fax: 563.344.0619
Email: vbrogan@qcbt.com

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, Asst. Vice President, Consumer Loan Officer
2040 1st Ave.
Moline, IL 61265
Phone: 309.277.2265
Fax: 309.764.1216
Email: gjipp@thenb.com

We recommend that you call all programs to compare interest rates.

 

Get Acquainted Session

Get Acquainted Session is for those who are looking for more information, but are just not ready to take the next step of scheduling a consultation with Dr. Van Raalte. This no-charge meeting to find out more about a particular procedure, the practice, or the physician, can be held individually or in a group. 

To schedule a 'Get Acquainted Session' contact our patient coordinator, Christina Drumm at (563) 322-8877 or by email