PATIENT INFORMATION

IF PATIENT IS UNDER AGE OF 18

PHYSICIAN INFORMATION

PHARMACY INFORMATION

ALLERGIES (Please list all medical allergies)

MEDICATIONS

HISTORY

CANCELLATIONS AND REFUNDS

Scheduling surgeries, requires careful planning and coordination between our office and our operating room staff, as well as our nurses. In addition, special medical instrumentation is prepared and sterilized for each individual procedure. Therefore, please understand the importance of respecting our “ Cancellation Policy” which entails the following (when it applies):

• Cancellations made 8-21 days prior to surgery/procedure date will result in forfeiting your deposit.

• Cancellations made at any time after deposit has been paid will result in forfeiting $2000 operating room fee.

• Cancellations made less than seven (7) business days from your date of surgery will result in forfeiting the total surgery/procedure fee. (Including, laser procedures, injectables, etc.).

• Cancellations one day before or on the day of the procedure will forfeit entire balance paid.

• All new patients pay $100.00 nonrefundable consultation fee.

A 4% or a minimum $35.00 service fee will apply to the total amount paid on any cancellation or rescheduling of an appointment or surgery.