Patient Forms & Information

Patient Forms

We have made the following patient forms available to expedite your initial visit with Belmont Plastic Surgery. Please download, print and complete the necessary forms then bring them with you to your appointment.

Feel free to call us at (540) 891-0040 if you have any questions regarding these forms. We look forward to seeing you.

Consent for Treatment

General Information for Our Patients

Medical Information

Belmont Surgery Center Letter

General Information

Patient Privacy


Insurance Information

Photography Consent

Cancellations Policy

  • 24-hour minimum notice is required for the cancellation or re-scheduling of any single service.
  • 48-hour notice is required for the cancellation of any multiple-service booking or spa package. Special requirements may apply for group bookings.
  • A full service charge will be incurred for any late cancellations or no-show appointments.

Any online cancellations must be made 48 hours prior to your scheduled appointment. Full service charges will be applied if you fail to contact us or do not show up for your appointment.

Specials Policy

All Online Specials, Multi- treatment Packages, Gift Certificate and Gift Card sales are final and non-refundable.


Belmont reserves the right to modify, discontinue, or raise prices on certain treatments without prior notification to ensure that maximum standards of service and quality are met. If you have any questions, please ask our Aesthetic Representative when you book your appointment.

Schedule your consultation with Belmont Plastic Surgery in Northern VA today

(540) 891-0040

Click Here to Schedule a Consultation Online