Cosmetic Surgery USA is a division of Advanced Patient Financing. For more information call (800)392-5189

Patient Profile Questionnaire

 

First Name Last Name Home Address City State Select your state      Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Email Address Phone Number What procedure are you interested in? When do you want this procedure? Select one           1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 12 months     What is your height? What is your weight? Do you have a physician? Select one Yes No If yes, please provide your physician's name Physician's location How would you rate your physical condition? Select one Good Average Poor Have you had any other cosmetic procedures? Select one Yes No If yes, please tell us when: Will you need financing? Select one Yes No If you do not need financing, stop here and submit.  If financing is needed, please answer the following questions. Your income Your total household income Social Security Number Date of birth Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1073 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 Employer's name Employer's phone number Employer's address City State Select your state Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip code How would you rate your credit? Select one Good Average Poor No credit established Promotion Code Authorization to Release Credit Information and Credit Policies By submitting this request to Cosmetic Surgery USA, (if financing is requested) I authorize “Advanced Patient Financing” (and/or their authorized lenders) to run a credit report and verify the information I have provided. I understand “Advanced Patient Financing” will be acting as a credit processing agent on my behalf and therefore does not approve, deny, set the rate and terms, guarantee loan approvals or discriminate against anyone for any reason. I agree to “hold harmless” “Advanced Patient Financing” from any and all legal actions that might be taken as a result of the cosmetic surgery I will be having. Check here to agree to these terms Submit Patient Profile