I NVOICE OF SURGICAL FEES

CG Cosmetic Surgery
Patient: Zuleika Burgos Physician: Robert Hunsaker,M.D
Date: 8/11/2020 Coordinator: Johanna Anzola
Procedure Date: 9/3/2020 Procedure Location: CG Cosmetic Surgery

Procedure(s): Standard Fee: Fee To Patient:

STANDARD MASTOPEXY Lifting my breasts by removing excess skin $6,000.00 $4,000.00

BILATERAL

SUBPECTORAL AUGMENTATION Enlargement of my breast by insertion of $5,000.00 $0.00

MAMMOPLASTY SILICONE silicone gummy implants under my
BILATERAL pectoral muscles

Subtotal: $11,000.00

Discount: <$7,000.00>

Surgeon's Fees: $4,000.00

Operating Room: $500.00
Anesthesia: $500.00

Other Fees: $1,000.00

Total: $5,000.00
Other Payments: <$5,000.00>
Balance Due: $0.00

DEPOSIT: Scheduling a surgical procedure requires the coordination of many different resources. This takes time to
handle properly so that the patient will enjoy a quality experience. You acknowledge and agree that upon execution
of this Invoice of Surgical Fees (the “Agreement”), Guiribitey Cosmetic & Beauty Institute, Inc. d/b/a CG Cosmetic
Surgery (“CG Cosmetic”) will incur certain costs and expenses in order to schedule and prepare for your
procedure(s). As such, you are required to pay to CG Cosmetic a one-time NONREFUNDABLE deposit in the
amount of $1,000.00 (the “Deposit”)concurrently with the execution of this Agreement. You agree and acknowledge
that the Deposit SHALL IN NO EVENT BE REFUNDABLE, NO MATTER THE CIRCUMSTANCES.
Specifically, failure to obtain medical clearance for any reason shall not entitle you to a refund.
You also understand that should your procedure(s) not occur within one (1) year from the execution date of this
Agreement, the prices quoted herein may be subject to change. Deposit is NON-TRANSFERABLE, and only
applicable to signed contract.

Zuleika Burgos (Aug 18, 2020 15:18 EDT)

Patient Signature: _________________________________________________

Robert Hunsaker,M.D
. . . . . . . . . . . . . . . . . . . . . . . . . . .
(305) 446-7277
Zuleika Burgos (Aug 18, 2020 15:18 EDT)