Patient Information

Forms & Notices

Access New Patient Forms and other informational documents for your convenience. We have provided these forms for download so you may complete them prior to your arrival at The Advanced Center for Plastic Surgery.

 

Care Credit Application

Financing is available through Care Credit. Apply using the link below:

care credit application

Patient Registration Form

This form is to be filled out by the patient. It consists of basic contact info, past and present medical history, and insurance information. This form also includes a copy of our financial policy and a photography consent form, if patient wishes to have photographs taken before/after surgery. Download form here. 

Notice to Patients

This notice describes how medical information about you may be used and disclosed. We are required by law to protect the privacy of your protected health information. This document also explains how you can gain access to your medical information and who to contact if you have any complaints. Please read the document carefully and sign the bottom of the form to acknowledge that you have received it. Download notice here. 

Financial Policy

Please review the following financial policies. As a part of requiring that all patients adhere to our policies, the following form must be signed and dated by both the patient and a witness. By signing this form, both patient and witness attest that the policy has been fully read, understood, and agreed upon by the signing patient. Download policy here. 

Patient Rights and Responsibilities

This document details a list of every patient’s rights & responsibilities, as well as contact information for questions and/or grievances. This document should be read in full then signed by the patient to acknowledge their understanding of the information. Download here. 

Accommodations and Nearby Hotel Information

Visiting us from out of town? Here are some recommended local hotels that are convenient to our practice.

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