Referring Drs.
It’s our goal to create a lasting and mutually beneficial relationship with our referring doctors. Click below to access our forms. You can fax or mail the forms to our office at the following:
You may print and complete these forms (PDF format) from the comfort of your own home.
- Patient Registration
- Patient History
- Photo Consent
- Patient History/Review of Systems
- Authorization to Release Health Information
- Medication List
- Authorization to Release Medical Records
- Consent for Treatment
- Notice of Privacy Practices
- Acknowledgment of Review of Notice of Privacy Practices
You will need to have Adobe Acrobat Reader installed on your computer to view these files. To download Adobe Reader click on the link below.
Address of Private Offices:
1420 Eighth Avenue
Suite 101
Fort Worth, TX 76104
Center For Aesthetic Surgery
75 Main Street
Suite 150
Colleyville, TX 76034