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PATIENT FORMS

To make sure we’re serving you the best we can, we want to keep you informed and aware of everything. Our previsit form gives you a full view of all the legalities regarding your surgery — and gives us a full view of your medical history. This document gets our team and you and your support system all on one page.

You can find the online form below to submit your information electronically or click the Paper Pre-Visit Form if you prefer to print out the forms. If you have any questions or concerns, feel free to contact our team.

Personal Information

Name
Address

Emergency Contact

Gender

Current Medications

If taking any aspirin, ibuprofen, advil (check below)
Medications
If no known allergies (check below)
Allergies
Weight Loss or Diabetes Medications (check if taking any of these):
Medical History (check all that apply):
Current or past cancer:
Prosthetic Device:

Social History

Tobacco use:
History of substance abuse:
Recreational drug use:
Alcohol use:

Release of Personal Information

Release of Personal Information

I hereby authorize representatives of Plastic Surgery Center of Duluth to speak with the following person(s) regarding my medical information (appointments, billing, etc).

Release of Information

Financial Responsibility: All professional services rendered are teh responsibility of the patient/guarantor.

Surgery covered by insurance: You will be responsible for your copayment, deductible, and/or coinsurance. Please be prepared to pay your required portion.

Informed consent patient before and after imaging:

During the course of the consultation, I may have been shown before and after photos of actual patients. I understand that those pictures are solely for the purpose of illustration of possible outcomes. I understand that any type of surgical procedure is related to my individual characteristics and health. Because of the differences in how individual living tissues react to surgery, there may be no relationship between the images observed and my actual final result.

Photographic images:

I authorize Dr. Saldana and his staff to photograph relevant areas of my body for documentation of care. I understand that this will be part of my medical record and will be used for diagnosis, treatment or educational purposes.

I consent to my photographs being used on Facebook or Instagram for before and after photos.

Authorization for treatment and insurance authorization:

I authorize the Plastic Surgery Center of Duluth to give me reasonable and proper care by today’s standards. I, the patient or responsible party, authorize release of medical information for the purpose of processing medical claims. I hereby authorize my insurance company to pay claims directly to the physician. I am financially responsible for non-covered claims.

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Areas of Concern

Areas of Concern (check all that apply):
What areas would you like to discuss today (check all that apply)?

Refund Policy

Gift Cards:

  • Gift cards are non-refundable and cannot be redeemed for cash or transferred to another individual.
  • Gift cards do not expire and may be used toward any eligible services or products offered at our practice.
  • Promotional gift cards or bonus credits issued during special events or promotions may have additional restrictions, as stated at the time of issuance.

Aesthetic Services:

  • Payments for aesthetic services are non-refundable once the service has been provided.
  • Prepaid packages for treatments are also non-refundable; however, unused portions may be applied toward other services or products within our practice.
  • If you are dissatisfied with the results of a service, we encourage you to contact us within [specific time frame, e.g., 7-14 days] to discuss your concerns. We will work with you to address the issue, as patent satisfaction is our priority.

Thank you for understanding our policies, which allow us to maintain the highest standards of care and service for all our paitents. If you have any concerns, please contact us at: (218) 215-8990 or info@duluthplasticsurgerycenter.com

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