Plastic Surgery Seattle | Cosmetic Surgery Bellevue

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Facial Surgery

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Patient Registration

On your first visit, you will need to complete a registration form and a medical history form. For your convenience, you may provide this information by filling out the online version of these forms below. Your information will be emailed to us at our office.

Last Name:

First Name:

Middle Initial:

Mr. Mrs. Miss Ms. Dr.

Date of Birth (mm/dd/yyyy) :

Address:

Street Address
City, State, Zip

Home Phone:

Work Phone:

Cell Phone:

Email:

Patient's Employer:

Patient's Occupation:

Marital Status:
Single Married
Widowed Separated Divorced

Spouse's Name:

Spouse's Employer:

Spouse's Occupation:

Person Responsible for Bill - Insurance Guarantor

Patient's relationship to person responsible for bill:
Self (skip to next section)
Spouse
Child
Dependent

Last Name:

First Name:

Middle Initial:

Address:

Street Address
City, State, Zip

Home Phone:

Work Phone:

Insurance Information

Primary Insurance:

Secondary Insurance:

Emergency Information and Release

In case of an emergency, local friend or relative to be notified
(not living at same address):

Name:

Relationship to Patient:

Home Phone:

Work Phone:

May we contact you to remind you about upcoming or missed appointments?
Yes No

Please provide your preferred contact phone number or email

Would you like to be excluded from mailings and email promotions?
Yes No

If you have any specific cosmetic interests, please check all that may apply:

Facial Surgery:	Body Surgery:	Non-Surgical:
Rhinoplasty	Breast Augmentation	Botox
Revision Rhinoplasty	Saline Breast Implants	Fat Injection
Face Lift	Silicone Breast Implants	Dermatology
Mini Face lift	Breast Reduction	Restylane
Neck Lift	Breast Lift (Mastopexy)	Sculptra
Mini Neck Lift	Breast Revision	Radiesse
Neck Liposuction	Breast Cancer Reconstruction	Juvederm
Septoplasty	Liposuction of Arms	Perlane
Nose Reshaping	Liposuction of Abdomen	Artefill
Brow Lift	Liposuction of Back	Dysport
Eyelid Lift	Liposuction of Flanks	Fotofacial
Ptosis Repair	Liposuction of Thighs	Intensive Fotofacial
Cheek Lift	Liposuction of Knees	Polaris for Wrinkles & Tightening
Chin Implant	Male Breast Reduction	Thermage for Face
Cheek Implant	Arm Lift	Thermage for Body
Feather Lift	Tummy tuck	Thermage for Cellulite
Laser Resurfacing	Mini Tummy Tuck	Treatment of Age Spots/Freckles
Facial Fat Grafting	Thigh lift	Laser Vein Removal
Lip Augmentation	Buttock Lift	Laser Hair Removal
Ear Reshaping	Lower Body lift	Sclerotherapy
Buccal Fat Removal	Body Fat Grafting	ToneAbrasion
Facial Skin Cancer	Body Skin Cancer	Zeltiq cryolipolysis
Facial Scar Revision	Body Scar Revision	Microdermabrasion
		Retinoic and Glycolic Peel

Please answer the following questions on a scale of 1 to 5:

When looking at my face in the mirror, I believe I look younger, the same as, or older than my true age.

Younger Than		True age		Older Than
1	2	3	4	5

When looking at my face in the mirror, the appearance of my face makes me:

Not Concerned		Somewhat Concerned		Very Concerned
1	2	3	4	5

I am looking for a procedure that can give me a:

Small improvement with minimal down-time		Moderate improvement with some down-time		Significant improvement with longer down-time
1	2	3	4	5

How did you hear about us?
(Check all that apply)

My physician
          (full name)
The yellow pages/telephone book
A friend or family member
          (name)
          May we contact him/her?   Yes    No
          Phone or Email:
Seattle Magazine's TOP DOCTORS
Internet search
          (Google, Yahoo, Other)
Online referral network
          (facialplasticsurgery.net, Other)

Newsletter or mailer
An article or advertisement in

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Plastic Surgery Seattle | Cosmetic Surgery Bellevue

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Patient Registration