Forms & Documents

Forms & Documents
You can save time by downloading and completing these forms in advance - then mail them to us or bring them with you at your appointment.

For your convenience we have provided our patient history and other forms in a format that you can download, print, and complete before your appointment. To save time when you arrive for your appointment, you can mail the completed forms to our office, or bring them with you at the time of your visit.


Required Forms (marked with *)


Patient History Form *
Information about your general health and your health history.

Consent To Treatment Form *
This is your consent to receive treatment at our Center.

Medications List And Acceptance Form *
Checklist for making your physician aware of your current medications.

The above 3 forms are required. Please complete all three forms and bring them along on your first visit.

Other Forms


Financial Policy
We strongly believe that an informed patient is a good patient and that your clear understanding of our financial policy is important to our professional relationship.

Records Release Form
Gives us permission to communicate with your insurance and other health providers.

Criteria For Breast Reduction
Document describing conditions for breast reduction.

Patient Satisfaction Survey
Tell us what you liked (or did not like) about your experience at Hickory Plastic & Reconstructive Surgery Center, and how we can serve you better.

All of our download forms and documents require the Adobe Acrobat reader, which most of you will already have.

download the Acrobat reader
Download the free Adobe Acrobat reader.


Hickory Plastic & Reconstructive Surgery Center ~ HickoryPlasticSurgery.com
50 13th Ave NE, Suite 2B ~ Hickory, NC 28601 ~ 828.322.8380
Specializing in breast enhancement and surgical and aesthetic procedures for the breast, body, face and skin
HickoryPlasticSurgery.com ~ Copyright © 2008-2016 Hickory Plastic & Reconstructive Surgery Center

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