Patient Form

Maximize your first visit

Please fill out the patient registration forms provided below prior to your first appointment. If you have any questions or need assistance, call us at 480-800-4501 or contact us.

Required fields are highlighted & marked with *

Patient Form
  • Patient Information
  • Cosmetic Treatments
  • Medical History
  • Pictures
  • Send
Patient Information


Home Address

Mailing Address


Emergency Contact



Due to the new HIPAA laws that are now in effect, we must have your written authorization to release your medical information to a person other then yourself. Understand that your information may need to be discussed with your current physician or any other member of your physician’s office and/or other medical facility in regards to the scheduling of procedures. Only the information needed to do this will be released. This release will be valid for one year from the date of signing.

Whon may we release your medical information to:

Cosmetic Treatments

I am interested in the following:

Choose Your Liposuction Areas of Concern

Please be as specific as possible

Why are you considering Liposuction?

VERY IMPORTANT!Tell Us About Your Previous Procedures

Medical History

Please fill out each section of the medical history form. If you have had no medical problems choose [no problems].


Please take photos in front of a plain background. For example, use a plain-colored wall or plain-colored sheet (white or blue is preferable) hung on a wall.

HIPPA Acceptance

Patient's Rights & Responsibilities

Sign Here


How can we help?