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.

Paper Pre-Visit Form

Personal Information

Today's Date

Name

First

Last

Date of Birth

Age:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

History abuse: (check

Occupation:

Emergency Contact

Name:

Relationship:

Phone

Primary Care Physician:

Referring Physician:

Preferred Pharmacy/Location:

Reason for visit:

Gender

Male
Female

Height:

Weight:

Current Medications

Current Medications/Doses:

If taking any aspirin, ibuprofen, advil (check below)

Medications

Aspirin
Ibuprofen
Advil

Allergies/Reactions

If no known allergies (check below)

Allergies

No known allergies

Current or past cancer:

Prosthetic Device:

Previous Surgeries/Serious Injuries (please give approximate dates):

Please list any other conditions not listed above:

Social History

Tobacco use:

Packs/day

If former smoker, how long smoke free:

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).

Name:

Relationship:

Phone

Name:

Relationship:

Phone

Release of Information

Please check box if you DO NOT authorize representatives of Plastic Surgery Center of Duluth to speak to anyone besides you.

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.

Please initial:

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.

Please initial:

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.

Please initial:

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

Please initial:

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.

Print Name:

Date:

Signature

Clear Signature

Areas of Concern

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

Print Name:

Date:

Signature

Clear Signature