Cosmetic Patients

Medical Questionnaire

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    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



    Pain Medication DependencyYesNo

    Psychiatric IllnessesYesNo


    Family History

    Do you


    Use Recreational drugs YesNo

    Use AlcoholYesNo

    Current Medications

    Over the counter, herbal, nutritional, etc.


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    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


    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)

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        How did you hear about us?

        Spouse 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

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          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

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          Dr Peterson Website Form min 1
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          Dr Peterson Website Form 3
          Dr Peterson Website Form 4
          Dr Peterson Website Form 5