Patient Forms

Patient Demographics

Name, Contact Information, Emergency Contact, Referred By and Insurance.

Health History

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.

Photography Release

Permission to take photographs, slides, and/or videotapes for marketing purposes.

Privacy Practices

Patient Rights regarding  protected health information (HIPPA).


Notice of Privacy Practices – Health Insurance Portability and Accountability Act (HIPAA).

Managed Care

Patients participating with an HMO must provide a referral or authorization number.

Disability Disclosure

Our office completes all disability forms and other miscellaneous paperwork at no cost.

Record Release

You may use this form to inspect, copy or request information maintained about you.