Cosmetic Patients

Medical Questionnaire

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Heart DiseaseYesNoHigh Blood PressureYesNoEpilepsyYesNo
SeizuresYesNoKidney DiseaseYesNoPhlebitis “blood clots”YesNo
Blood TransfusionYesNoThyroid diseaseYesNoWound healing problemsYesNo
HepatitisYesNoWalk 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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