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Patient Information and Medical Evaluation

Patient Information and Medical Evaluation

Maximize your first visit

Please fill out the patient registration forms provided below prior to your first appointment. If you have any questions or need assistance, call us at 480-470-6205 or contact us.

Required fields are highlighted & marked with *

Patient Info - merge
  • Patient Information
  • Medical Evaluation

Patient Information

Home Address

Mailing Address

Emergency Contact

Authorization

Due to the new HIPAA laws that are now in effect, we must have your written authorization to release your medical information to a person other then yourself. Understand that your information may need to be discussed with your current physician or any other member of your physician’s office and/or other medical facility in regards to the scheduling of procedures. Only the information needed to do this will be released. This release will be valid for one year from the date of signing.

Medical Evaluation

Cosmetic Treatments

I am interested in the following:

Medical History

Please fill out each section of the medical history form. If you have had no medical problems choose [no problems].

HIPPA Acceptance

Patient's Rights & Responsibilities

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