Cosmetic Patients

Medical Questionnaire



Asthma YesNo Diabetes YesNo Migraines YesNo
Heart Disease YesNo High Blood Pressure YesNo Epilepsy YesNo
Seizures YesNo Kidney Disease YesNo Phlebitis “blood clots” YesNo
Blood Transfusion YesNo Thyroid disease YesNo Wound healing problems YesNo
Anemia YesNo Steroids/Prednisone YesNo Stroke YesNo
Hepatitis YesNo Walk with a walker or cane YesNo




Diet Pills/Herbal SupplementsYesNo



MammogramYesNo



MRSA/StaphYesNo



Pain Medication DependencyYesNo






Psychiatric IllnessesYesNo




Hospitalization/Surgeries






Family History








Do you



SmokeYesNo




Use Recreational drugs YesNo



Use AlcoholYesNo



Current Medications



Over the counter, herbal, nutritional, etc.










PAYMENT POLICY

Thank you for choosing my office for your cosmetic procedure. The staff and I are committed to your treatment being
successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our financial policy that we require you to read and sign prior to any type of reatment. All patients must complete our patient information.

We require a 20% non-refundable deposit of the surgeon’s fee to guarantee your surgery date and time. Surgeries cancelled within 72 hours of scheduled surgery date will be subject to a 20% surgeon’s fee.

Payment for all cosmetic surgical procedure is due in full prior to surgery. We gladly accept personal check, cash, Visa, Master Card, American Express & Discover. A $25.00 return check charge will apply to all returned checks. We do not accept postdated checks and will not hold checks.

We offer financing with Care Credit

1-800-365-8295

www.carecredit.com

Follow up Visits & Surgery Revisions

After 6 months there is a $75.00 follow up charge for all office visits. All revision or touches up surgeries are subject to hospital, anesthesia and surgeon’s fee.

Other Fees

Postage = $4.95 Billing Records = $25.00 Each additional page = $0.50 Medical Leave Forms = $50.00 Medical Records (1st 20 pages) = $25.00

I have read and understand the above information regarding payment, follow up visits, surgery revisions and other fees.

I have read and understand the above information regarding payment, follow up visits, surgery revisions and other fees.


Patient Registration (Cosmetic)















How did you hear about us?








Spouce Information








Photographic Consent



The following is my consent for Dr. Peterson or a staff representative to photograph me for the following purposes. Using respectful and discretionary measures, the photographs may be viewed by medical health care professionals, as well as nonmedical individuals.


- Patient’s file Photographs are required for the patient’s file and will be utilized for comparative review during the course of treatment.

- Office reference These photographs may be used for educational purposes.

- Internet The discreet use of photographs may be used exclusively on Dr. Peterson’s educational website.



By signing, I am granting Dr Peterson permission to use my photographs as checked above.






Acknowledgement of Review of

Notice of Privacy Practices



I have reviewed the office's Notice of Privacy Practice, which explains how my medical information will be used and disclosed. I understand that i am entitled to receive a copy of this document.











Your Rights