Patient Forms

Please select the necessary forms below. Print, complete and bring with you on your first visit.

New Patient Information

Your initial visit will be for an evaluation only.

INSURANCE-RELATED CONSULTS
Patients are responsible for:

  • Ensuring that our office receives medical records pertinent to your upcoming visit
  • Bringing your insurance cards (you will be considered self-pay until we receive a copy)
  • Referral (if required)
  • Specialist co-pay or co-insurance

COSMETIC-RELATED CONSULTS
Please be aware that insurance does not cover elective cosmetic procedures. Consult fees will be collected at your initial consultation. If you schedule surgery under general anesthesia, the consult fee will be deducted from the total fee of your surgery (consult fees are generally $95 – $121).

ACCEPTED METHODS OF PAYMENT
Cash, Cashier’s Check, Money Order, Visa, MasterCard, American Express, Personal Check (up to $1000.00), Alphaeon Credit and Care Credit (cardholder must be present to use Care Credit or Alphaeon Credit card and two forms of ID will be required). If you are interested in using Care Credit or Alphaeon Credit , you may visit their websites at:

You may call Care Credit at 1-800-365-8295 or Alphaeon Credit at 1-855-497-8176. Not all plans listed on the Alphaeon Credit and Care Credit websites/brochures are offered to our patients. Please check with our office staff for more information.

CHILD CARE
Children are NOT allowed in our patient care areas. Therefore, we encourage you NOT to bring children under the age of 16 with you.

If you are visiting our office for BOTOX®, JUVÉDERM®, or LATISSE®, be sure to register with Brilliant Distinctions before your appointment so you can begin earning points on your next visit.

Patient Forms

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Health History Questionnaire

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Demographic Form

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HIPAA NOTICE

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Skin Care New Patient Form

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Breast Reduction Guidelines