Forms

For New Patients

If you have scheduled an appointment with our office, please download and complete the following patient forms to help reduce your time in the waiting room.

Give us a call if you have completed the forms and we might be able to move your appointment up by as much as 15 minutes.

If you have any questions please do not hesitate to call us at (727) 522-FACE (3223).

These links open in a new window:


Patient Questionnaire Form

HIPPA Consent Form

For Disclosure Of Health Information

Patient History Form

Patient Information Form

Patient Medical History Form

Patient Photo Release Form

FAQ`s About Facial & Eye Plastic Surgery

In addition to these forms, please bring the following items:

  • Insurance cards
  • A list of all your current medications
  • Many elective cosmetic procedures are not covered by insurance. Many insurance plans require an authorization for a visit to our office. Please check your plan and, if necessary, obtain an authorization from your primary care physician.



We’re so glad that you have chosen to visit us. We look forward to seeing you soon.


Financing

As a service to our patients, we are pleased to offer CareCredit, the nation’s leading patient payment program. With CareCredit you can finance 100% of your cosmetic surgery and there are no upfront costs, no annual fees, and no pre-payment penalties. So, you can schedule your procedure today and conveniently pay with low, monthly payments.

CareCredit offers a full range of payment plans so you can find one that works best for you.

No Interest Payment Plans

  • 3, 6, & 12 month plan options
  • No interest if the balance is paid within the specified time period
  • Low minimum monthly payments

Extended Payment Plans

  • 24, 36, & 48 month plan options
  • For treatment fees from $1,000 to over $25,000
  • Competitive interest rate
  • Monthly payments as low as $76 on a $3,000 procedure fee

Click here to view the financing and payment details.

With CareCredit, you have a revolving credit line for repeat procedures, without the need to re-apply. It only takes a few minutes to apply for CareCredit and you may receive an online decision in seconds! Apply now or see our staff for more details.

St. Petersburg Office

Kass Center for Cosmetic Surgery

6025 4th Street North
St. Petersburg, FL 33703
Contact Information
Hours: contact us

Clearwater Office

Kass Center for Cosmetic Surgery

1811 North Belcher Rd Suite H-1
Clearwater, FL 33765
Contact Information
Hours: contact us