Las Colinas Centre for Plastic Surgery

Michael R. Whetstone, M.D. Board Certified Plastic Surgeon
Las Colinas Centre for Plastic Surgery
Free Consultation
972-831-8822

Patient History Form

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PATIENT HISTORY

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PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE

I authorize the release of any medical and personal information necessary for my care and treatment. I authorize the release of any medical information necessary to process insurance claim(s). I authorize payment of medical benefits to the physician for services rendered, and further understand that I am responsible for coinsurance, deductibles, and co-payment amounts as determined by my insurance carrier. Patients who carry Health Care Insurance should remember that professional services are rendered and charged to the patient and not the Insurance Company. We will submit charges to your Insurance Company as a courtesy; however, payment of your account is your responsibility.