On this page, we are showing New Patient Forms and other informational documents for your convenience. We have provided these forms for download so you may complete them prior to your arrival at The Advanced Center for Plastic Surgery.
• Patient Registration & Consent Form
This form is to be filled out by the patient. It consists of basic contact info, past and present medical history, and insurance information. This form also includes a copy of our financial policy and a photography consent form, if patient wishes to have photographs taken before/after surgery.
• Notice to Patients
This notice describes how medical information about you may be used and disclosed. We are required by law to protect the privacy of your protected health information. This document also explains how you can gain access to your medical information and who to contact if you have any complaints. Please read the document carefully and sign the bottom of the form to acknowledge that you have received it.
• Financial Policy for Cosmetic Patients
• Financial Policy for Insurance Patients
Please review the following financial policies. As a part of requiring that all patients adhere to our policies, the following form must be signed and dated by both the patient and a witness. By signing this form, both patient and witness attest that the policy has been fully read, understood, and agreed upon by the signing patient.
• Credit Card HIPAA Release
Each patient is required to submit a signed release statement for the credit card that will be used to pay for the procedure
• Patient Rights & Notification of Physician Ownership
This document details a list of every patient’s rights & responsibilities, as well as contact information for questions and/or grievances. This document should be read in full then signed by the patient to acknowledge their understanding of the information.