Name *

Email Address *

Surgeon's Name *

Procedure to be Performed *

Abdominoplasty Breast Augmentation Breast Lift Breast Reduction Brow Lift Buttock Lift Cheek Implants Chin Augmentation Eyelid Surgery Facelift Gynecomastia Liposuction Lower Body Lift Otoplasty Rhinoplasty Thigh Lift Upper Arm Lift Other Multiple

City *

State *

Comments *

• Submit

Don’t see your surgeon’s name on the list of participating surgeons? No problem!

Simply complete this form and we’ll be happy to contact your surgeon’s office regarding CosmetAssure. The only way to receive CosmetAssure coverage is to have surgery with a CosmetAssure participating surgeon. Patients cannot purchase CosmetAssure directly through the insurance provider. If you’d like to receive more information about the program, please contact a CosmetAssure Representative.

CosmetAssure
Email: info@cosmetassure.com
Phone: 800.362.1542