Patient Forms

Plastic Surgery Centre of Atlanta specializes in plastic surgery for the face, breasts, and body as well as medical spa treatments for men and women in Atlanta, Sandy Springs, Buford, Suwanee, Newnan, and Kennesaw. Please review and complete our patient forms before your consultation appointment.

Please use the link below to download our patient forms.

 

Pre Registration Form

(A copy of the filled out form will be sent to this email)


PATIENT INFORMATION






FM


SMDW










Cell
Email


EmployedHomemakerRetiredStudent



GUARANTOR OR RESPONSIBLE PARTY


Yes












Emergency Contact




YesNo




YesNo


PATIENT MEDICAL HISTORY




YesNo



YesNo


DailyWeekly


YesNo



YesNo


YesNo



Bleeding Disorder
Blood Clots
Breast Cancer
Psychiatric Disorder



YesNo







YesNo


**Women Only**


YesNo






Place a check mark if you have or have had any of the following conditions listed below:

Anemia
Aneurysm
Angina or Chest Pains
Anxiety Disorder
Arrhythmia
Asthma
Bleeding Disorder
Blood Transfusion
Breast Cancer
Cancer
Cold Sores
Congestive Heart Failure
COPD
Deep Vein Thrombosis
Depression
Diabetes
Dry Eye Syndrome
Epilepsy
GI Problems
Glaucoma
Heart Disease
Heart Murmur
Hepatitis
HIV/AIDS
Hypertension
Liver Disease or Jaundice
Lupus
Keloid Scars
Polycystic Ovary Disease
Rosacea
Vitiligo
Tattoos
Mitral Valve Prolapse
Muscular Dystrophy
Myocardial Infarction
Nasal Airway Obstruction
Peripheral Vascular Disease
Pneumonia
Polio
Polyarthritis Nodosa
Prostate Cancer
Psoriasis
Pulmonary Disease
Recent Weight Loss
Renal Disease
Rheumatic Fever
Rheumatoid Arthritis
Sarcoidosis
Seizure Disorder
Skin Cancer
Stroke
Thromboembolism
Thyroid Disease
Transient Ischemic Attacks
Tubal Pregnancy
Tuberculosis
Urinary Tract Infections
Varicose Veins
Visual Problems
Pacemaker
Acne
Facial Fillers/Botox/Dysport
Implants
Permanent Makeup

Separate Corporate Entities:
I understand Plastic Surgery Centre of Atlanta, PC (David B. Brothers, MD, FACS) and Crispin Plastic Surgery (Mark E. Crispin, MD, FACS) are separate Georgia corporations. I understand Alchemy Aesthetics is a subsidiary of Plastic Surgery Centre of Atlanta, PC.



Receipt of Notice of Privacy Practices Written Acknowledgement Form:
I have received a copy of the Notice of Privacy Practices.



Payment Agreement:
I have been informed that Dr. Brothers is out-of-network with specific insurances. I understand Plastic Surgery Centre of Atlanta, PC will file my claim with my primary insurance company only. I am responsible for any co-payment after my primary insurance has processed my benefits. I also authorize Plastic Surgery Centre of Atlanta, PC to appeal on my behalf for reimbursement of services rendered.



Authorization of Release of Information:
I authorize the release of any information, including the diagnosis and records of any treatment or examination rendered to me or my child during the period of such care to third party payers and/or other health care practitioners. I authorize and request my insurance company to pay DIRECTLY to the doctor or doctors corporation insurance benefits otherwise payable to me unless I have already paid. I understand my insurance carrier may pay less than the actual bill of services. I agree to be responsible for payment of all service rendered on my behalf or my dependents.



Photography Consent:
I hereby authorize Plastic Surgery Centre of Atlanta, PC and David B. Brothers, MD to take confidential photographs of myself in whole or in part for ONLY MY MEDICAL RECORDS OR INSURANCE IF REQUESTED. These photographs will remain property of the above named corporation.




Skin care advice
Skin care products
Injectable Treatments
Botox/Juvederm
Facial fine lines/wrinkles
Thin lips
Forehead wrinkles
Frown lines
Crows feet
Liposuction
Breast Enhancement
Smile lines
Brown spots/age spots
Drooping brow
Length of eyelashes
Mole removal
Scar revision
Excessive sweating
Arm lift
Laser resurfacing
Thigh lift
Earlobe repair
Neck wrinkles
Sun damage
Eye lift
Facial redness
Unwanted hair
Dark undereye circles
Eye puffiness
Stomach
Breast reduction
Breast lift
Facelift

Skincare Questionnaire

**FOR AESTHETICIAN CONSULTATIONS ONLY**


Aging Skin
Acne
Wrinkles
Lip lines
Sun damage/brown spots
Enlarged Pores
Oily Skin
Rough texture
Unwanted hair
Thin lips
Spider veins
Frown lines
Rosacea
Dry Skin
Redness
Scars
Stretch Marks
Saggy Skin
Unwanted fat
Sensitive Skin
Other



YesNo



YesNo



YesNo


Highly sensitive skin, always burns, never tans
Very sun sensitive skin, burns easily, tans minimally
Sun sensitive skin, sometimes burns, slowly tans to light brown
Minimally sun sensitive skin, burns minimally, always tans to moderate brown
Sun insensitive skin, rarely burns, tans well
Sun insensitive, never burns, deeply pigmented


Led by board-certified plastic surgeon, Dr. David B. Brothers, Plastic Surgery Centre of Atlanta specializes in cosmetic and reconstructive plastic surgery as well as advanced medical spa treatments for men and women in the Atlanta area. Contact us today to schedule your personal consultation!