Name, Contact Information, Emergency Contact, Referred By and Insurance.
Past medical condition, Medications, Allergies, Surgical History and Family History.
Payment For Services
We accept cash, checks, Visa, MasterCard, American Express, Discover and Cosmetic Protect.
Permission to take photographs, slides, and/or videotapes for marketing purposes.
Patient Rights regarding protected health information (HIPPA).
Notice of Privacy Practices – Health Insurance Portability and Accountability Act (HIPAA).
Patients participating with an HMO must provide a referral or authorization number.
Our office completes all disability forms and other miscellaneous paperwork at no cost.
You may use this form to inspect, copy or request information maintained about you.