Chesterfield, MO
(636) 530-6161
Please fill out our New Patient Form below and provide as much information as possible. If we have any further questions you will be contacted accordingly.
NOTE: Signature section below may malfunction in Google Chrome (PC & Mac). Please use FireFox or Safari browsers (PC or Mac) on your desktop, tablet, or mobile device to complete this form. It will help ensure accuracy in all information and proper submission.
Personal Information
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Employment Information
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Payment Policy
Because our services are rendered to YOU, you are responsible directly to us for settlement of your account within the time limit set. Please feel free to discuss your bill or charges at an early date, to avoid misunderstandings.
It is understood that failure to comply with this agreement would leave St. Louis Cosmetic Surgery, Inc. no alternative but to seek collection action.
The quote that you receive at your consult will include the doctor’s fee, plus OR and anesthesia. Payment of these fees will be due prior to surgery.
Due to the HIPAA (Health Insurance Portability and Accountability Act) all information must be completed on this form and the following forms. If you have any quesitons regarding this, anyone in our office will be glad to help you.
Thank you for choosing St. Louis Cosmetic Surgery