Patient Info and Forms

New Patient Info

During your first appointment with us, we will begin with a consultation with Dr. Ghaznavi to review your treatment goals. Dr. Ghaznavi will perform a detailed examination of the area you would like to address and provide you with your treatment options, what to expect from treatment and estimated costs. If you have any questions, you can call us at 571-526-0879, fax us at 571-621-7593, or request an appointment online.

New Patient Forms

For your convenience, our new patient forms can be completed online. To save time during check-in, simply click the buttons for the forms below, and complete them prior to your appointment with us.

Financial Policy and Procedures

1. Consultation Fee for In-Office/Virtual Visit
   • No fee is charged for consultations at this time.
   • A valid credit card is still required to book.
2. Consultations In-Office/Virtual Visits
   • Cancel or reschedule over 48 Hours in Advance: No fee. 
   • Cancel or reschedule under 48 Hours: $250 Late Cancellation Fee. 
   • No-Show: Missed appointments or arriving more than 10 minutes late without notice result in a $250 No-Show Fee. 
   • Grace Waiver: One-time waiver per patient, documented in EMR.
   • Exemptions: Medical emergencies, severe weather, and practice-initiated changes are exempt from fees.
3. Payment & Authorization
   • We accept credit cards over the phone or online, in-person cashier, or e-checks, cash, or  financing  through one of our trusted partners. 
   • Fees are automatically charged to the card on file if cancellation or no-show policies apply.
   • Payment is due in full at least 4 weeks prior to the scheduled surgery date. Delay in payment may  result in the need to postpone surgery.
4. Surgical Deposits
   • Surgical deposit is 20% of the total surgical fee. 
   • No requests or scheduling of surgical dates are made until the deposit is paid.
   • This deposit is applied toward the total cost of the service.
   • Refund Policy:
     • If a patient cancels 30 days or more before surgery, the deposit is fully refundable.
     • If a patient cancels between 14–29 days before surgery, 50% of the deposit will be refunded.
     • If a patient cancels within 14 days of the scheduled surgery, the deposit is non-refundable.
     • If a patient reschedules a surgery and later cancels, the refund policy will follow the new surgical date’s timeline.
5. Surgical Rescheduling Policy
   • Patients are allowed one courtesy reschedule of their surgery without penalty, depending on the  timing of their request.
   • Rescheduling Requests Made 30 Days or More Before Surgery: 
     • The first reschedule is free of charge. 
     • If a second reschedule is requested: A $750 non-refundable rescheduling fee will apply .
     • The surgical deposit remains refundable if the new surgery is later canceled ≥30 days in advance. 
   • Rescheduling Requests Made Between 14–29 Days Before Surgery: 
     • One reschedule is allowed without a fee. 
     • A second reschedule is not permitted: 
       • The patient must cancel and rebook. 
       • In this case, 50% of the original deposit is forfeited. 
       • Any balance already paid beyond the deposit will be refunded. 
       • The patient will need to place a new deposit to secure a future date. 
       • New procedure pricing and terms may apply if rebooked at a later date. 
   • Rescheduling Requests Made Within 14 Days of Surgery: 
     • One reschedule is allowed but will incur a $750 non-refundable rescheduling fee.
       • At this stage, the entire surgical deposit becomes non-refundable. 
       • A second reschedule is not allowed: 
         • The surgery must be canceled. 
         • The entire deposit is forfeited. 
         • Any remaining surgical balance paid will be refunded. o A new deposit is required to rebook a new date
   • If AMG or Your Surgeon Reschedules: 
     • If AMG Plastic Surgery or your surgeon initiates the reschedule for any reason:
       • There is no fee charged. 
       • Your surgical deposit and remaining balance remain fully intact.
6. How to Cancel or Reschedule
   • Call 703-239-3190 or use Klara during business hours (Mon–Fri, 9 AM–5 PM).
   • Texts, social media, or voicemail cancellations will NOT be accepted.
   • We send multiple texts and email reminders as a courtesy.
7. Cosmetic Surgery Quote Breakdown
   • A quote is valid for ninety (90) days from the date it is signed. After 90 days, AMG Plastic Surgery reserves the right to re-evaluate and adjust pricing. The quote covers the following: 
     • Surgeon’s Professional Fee 
     • Facility Fee 
     • Anesthesia Services 
     • Pre-op and Post-op Visits 
     • Medical Equipment (e.g., Implants, Mesh, Prevena, Renuvion, Botox, Filler, Sculptra)
     • Not included: 
       • Prescription Medications
       • Lab test or any required medical clearance
8. Surgical Clearance
   • Patient is responsible for costs related to: 
     • Lab work 
     • EKGs 
     • Imaging 
     • Medical clearances 
     • Prescriptions
     • Pathology
9. Revision and Complication Policies
   • AMG Plastic Surgery makes every effort to achieve optimal results, but due to the nature of surgery,  no promises or guarantees can be made regarding outcome, appearance, or satisfaction.
   • In the event of complications (e.g. healing issues, scarring, infection), the patient may incur  additional charges for corrective or revision procedures, unless otherwise agreed in writing.
   • Revision procedures may incur additional facility and anesthesia fees.
   • Refunds will not be issued based solely on dissatisfaction with cosmetic outcome if the procedure was performed in a medically appropriate manner and according to the standard of care.
   • Revisions may be discounted at the surgeon’s discretion within 12 months of surgery.
10. Insurance Policy
    • Our practice accepts a limited number of insurance plans for medically necessary (reconstructive)  procedures. 
    • Cosmetic procedures are not covered and cannot be billed for partial insurance after surgery.
    • Insurance claims are filed as a courtesy; patients are ultimately responsible for any balance due. 
    • Those procedures deemed NOT medical necessity by insurance can request an out-of-pocket  estimate.
    • It is the patients’ responsibility to obtain estimates and EOBs from their own insurance  company.
11. Payment Methods and Financing Options
    • We accept: 
      • Cash, Visa, Mastercard, Discover, American Express 
      • Personal Checks  
      • Must be received 14 days before surgery. Any returns checks incur a $50 return fee. 
      • We partner with CareCredit® ,Cherry™, Northwest Credit Union to provide flexible monthly payment  options for qualified applicants. 
    • Financing Terms: 
      • Subject to approval.
      • Financing applications should be completed at least 30 days before scheduled surgery.
      • Third-party financing must be confirmed prior to final payment due dates

Version 10.13.2025

Online Bill Pay

Insurance

In Network

• Carefirst- Bluechoice, Regional PPO and PPO
• Medicare- Part B and Part D
• Anthem Blue Cross Blue Shield
• United

Out Of Network

• Aetna – PPO, EPO, HMO, Medicare HMO and Medicare PPO
• Cigna – Open access plus, open access local plus, PPO and HMO
• Tricare East Region
• Tricare For Life

Do Not Accept

• Medicaid
• Humana
• Aetna Innovation/INOVA Health
• Anthem HealthKeepers
• Magellan of Virginia
• Cigna EPO

We are proud to offer our patients financing options such as CareCredit and Alphaeon Credit Card. We believe that everybody deserves to feel their best, and we strive to make paying for your treatment and procedures with us as convenient as possible. Please read more about our financing options below, and call or text (571) 526-0879 if you have any questions!

Financing Options

CareCredit

AMG Plastic Surgery is proud to accept healthcare financing with CareCredit. CareCredit offers financing plans as convenient as 24 months with no interest, to help you pay for your health, wellness and personal care needs.

Learn More And Apply Today

Cherry Financing

AMG Plastic Surgery is pleased to offer Cherry Financing, providing patients with a convenient option for managing the expenses of cosmetic treatments. Through Cherry, patients have the opportunity to divide costs of cosmetic procedures, up to $30,000, into monthly payments that are easy to handle. The payment plans are flexible, ranging from 3 to 60 months, to accommodate various financial situations. Additionally, patients can benefit from 0% APR* options, making aesthetic enhancements accessible and affordable for everyone. For example, a $400 payment plan with Cherry may cost $100/month over 3 months at 0% APR with down payment in the amount of monthly payment due at the time of purchase.

*0% APR and other promotional rates subject to eligibility

Alphaeon Credit Card

With the Alphaeon Credit Card*, You Get:

• A wide array of monthly payment options to help you reach your individual goals
• Special financing plans that are not always readily available with traditional credit cards
• The ability to use your card again for yourself or family members with no need to reapply and no annual fee

Your Best You is Closer than You Think!

*Subject to credit approval and availability. Purchase must be made using the ALPHAEON CREDIT Card Account. ALPHAEON CREDIT Card Accounts are offered by Comenity Capital Bank which determines qualifications for credit and promotion eligibility. Account must be in good standing at the time of purchase. At no time will the minimum payment due be less than $27.00. Minimum interest charge is $2.00 per credit plan. Standard variable APR of 28.99%, based on the Prime Rate. Comenity Capital Bank issues ALPHAEON CREDIT Card Accounts, which can be used with participating physicians.

Learn More and Apply Today

Patient Resources

At AMG Plastic Surgery in Herndon, VA, we aim to thoroughly educate our patients so they can make the best and most informed decisions about their care. To help make your treatment journey go smoothly and seamlessly, we have provided patient resources including information about your recovery, videos and more. If you have any questions, please call us at (571) 470-6031 or fill out the contact us form on our website.

• Prepare for a smooth recovery after plastic surgery
• Can you speed up your recovery after plastic surgery?
• Breast implant safety
• Preparing for plastic surgery
• Cosmetic surgery: What to know beforehand
• Tummy Tuck Recovery: Timeline, Tips, and More
• Your facelift recovery explained from Day 1 to Day 30
• Nine tips from a plastic surgeon and patient for a smoother recovery