Contáctese con Bal Harbour Surgery en Miami para programar una consulta con nuestro cirujano certificado por el consejo Dr. Michael Salzhauer.

Dr. Michael Salzhauer
Bal Harbour Plastic Surgery
1140 Kane Concourse
Bay Harbor Islands, FL 33154
Tel (305) 861-8266
Fax (305) 356-7909





Please fill out and submit the application below. One of our Patient Coordinators will contact you shortly to discuss your financing options, or for immediate assistance call 305-861-8266.

**ALL Applicant and Employer Information must be filled out completely in order to be processed.

Loan Information
Total Amount of Loan What procedures would you
like to finance?
$
Applicant Information
First Name * Last Name *
   
Middle Name Mothers Maiden Name
   
Social Security # * Date of Birth (month, day, year) *
  - -   / /
Email Address *
 
Current Address * Time at Current Address *
    years months
City * State *                Zip *
     
Housing * Monthly Rent/Mortgage *
   
Home Phone * Alternate Phone
   
Complete below if applicant has moved in the last 2 years
Previous Home Address Time at Previous Address
    years months
City State                   Zip
     
Employer Information
Employer Name * Position *
   
Income * Payment Schedule *
   
Employer Address * Time at Current Employer *
    years months
City * State *                Zip
     
Business Phone *
 
Other Income Source of other income
   
Complete below if applicant has changed jobs in the last 2 years
Previous Employer Position
   
Previous Employer Address Time at Previous Employer
    years months
City State                   Zip
     
Co-Applicant Information (Not Required)
First Name Last Name
   
Middle Name Relationship to Applicant
   
Social Security # Date of Birth (month, day, year)
  - -   / /
Current Address Time at Current Address
    years months
City State                   Zip
     
Housing Monthly Rent/Mortgage
   
Estimated Property Value Current Mortgage Balance
   
Home Phone Alternate Phone
  - -   - -
Driver's License State Driver's License #
   
Complete below if Co-applicant has moved in the last 2 years
Previous Home Address Time at Previous Address
    years months
City State                   Zip
     
AUTHORIZATION TO RELEASE CREDIT INFORMATION AND POLICIES
By my signature, I authorize "Bal Harbour Plastic Surgery" to submit to a loan processing company to run a credit report and verify the information I have provided. I understand "Bal Harbour Plastic Surgery" will be acting as my credit-processing agent and therefore does not approve, deny, set the rate and terms, guarantee loan approvals or discriminate against anyone for any reason. As a part of this search, I fully understand my credit request may be presented to multiple credit issuing companies and/or search companies including (but not limited to) Banks, Finance Companies, Credit Card Issuers, and partnership programs with other such affiliated companies. I understand that I will be charged loan processing fees for these services. Furthermore, while calculated monthly, I understand that the total amount of the fees will be added to my base loan amount requested and become a part of my principal balance in most cases. I agree to "hold harmless" "Bal Harbour Plastic Surgery" from any and all legal actions that might be taken as a result of a disputed matter with my Service Provider or Vendor.
Please Print Your Name
    I agree


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Vea las Apariciones
Recientes en los Medios del
Dr. Salzhauer

EL PACIENTE Y CUALQUIER OTRA PERSONA RESPONSABLE POR EL PAGO TIENE EL DERECHO DE NEGARSE A PAGAR, CANCELAR EL PAGO, O RECIBIR REEMBOLSO POR EL PAGO DE CUALQUIER OTRO SERVICIO, EXAMEN O TRATAMIENTO QUE SEA PRACTICADO COMO RESULTADO DE Y DENTRO DE LAS 72 HORAS DE RESPONDER AL AVISO POR LOS SERVICIOS, EXAMENES O TRATAMIENTOS GRATUITOS, O CON TARIFAS REBAJADAS O DESCONTADAS.