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(915) 543-5600

 

 

FALL SPECIALS Westside Location
The Cosmetic Laser & Surgery Center of El Paso (westside location) is offering Fall Specials now thr...

Patient Registration - For Patients With Scheduled Appointments Only

Dr. Weeks, Dr. Jabor, and their El Paso, Texas Cosmetic Surgery staff will be happy to answer any questions or address any concerns. To ensure that you are promptly seen or if you are unable to keep your appointment, please call us 24 hours in advance.

Patient

* First Name:
Middle Name:
* Last Name:
* Address:
* City:
* State:
* Zip:
* Home Phone:
Cell Phone:
Other Phone:
Any restrictions contacting you? Yes
No
If so, please specify:
E-mail:
Drivers License Number:
Drivers License State:
Age:
Date of Birth (mm/dd/yyyy):
Social Security Number:
Sex: Male    Female Male
Female
Marital Status:
Single
married to:
other:

Patient's Employer

Employer:
Occupation:
Work Phone:
Extension:
Is it okay to call you at work?: Yes
No
Address:
City:
State:
Zip:

Emergency Contact

Emergency Contact Name:
Emergency Contact Relationship:
Emergency Contact Home Phone:
Emergency Contact Work Phone:
Emergency Contact Other Phone:
Emergency Contact Street Adress:
Emergency Contact City:
Emergency Contact State:
Emergency Contact Zip:

Primary Insurance


This section may be skipped if not applicable to your procedure.
Insurance Company:
Policy #:
Group #:
Insurance Phone:
Referral Required: Yes
No
Copay: Yes
No
Copay Amount: $
Insured Name:
Insured Date Of Birth:
Insured Employer:

Secondary Insurance

Insurance Company:
Policy #:
Group #:
Insurance Phone:
Referral Required: Yes
No
Copay: Yes
No
Amount: $
Insured Name:
Insured Date Of Birth:
Insured Employer:

Referral Information

* How did you hear about our office?
* Referred by:

Questionaire

Smoker: Yes    No   
Procedure Interested In:
Allergic To:
Current Medications:
History of Problems with Anesthesia? Yes    No   
If so, please provide details:
Past Surgeries? Yes    No   
If so, please list:
DO YOU HAVE PROBLEMS WITH:IF "Yes" PLEASE DATE ("mm/yyyy")
Heart/Heart Murmur: No    Yes   
Diabetes: No    Yes   
High Blood Pressure: No    Yes   
Asthma: No    Yes   
Stroke: No    Yes   
Kidney Problems: No    Yes   
Lung Disease: No    Yes   
LiverDisease/Hepatitis No    Yes   
Cancer: No    Yes   
Eye Problems: No    Yes   
HIV Positive: No    Yes   
Bleeding Problems: No    Yes   
Pregnant: No    Yes    LMP:
Illegal Drug Use: No    Yes   
Have you had a mammogram? No    Yes   
History of Breast Problems/Procedures: No    Yes   
Family/Personal history of blood clot formation of extremities: No    Yes   
Other medical problems not mentioned:
Height:
Weight:
Are you currently under treatment? Yes    No   
Family Doctor/Specialist treating you?
For what condition?
I understand that office visit charges are payable on the day service is rendered. I authorize Dr. Mark A. Jabor and/or Dr. Lyle D. Weeks to bill my insurance company. Regardless of insurance coverage, I am responsible for all bills being paid in a timely manner. I understand that my contract is between Dr. Mark A. Jabor, Dr. Lyle D. Weeks and myself.
* Please Confirm:
   * required fields
© 2008 - Cosmetic Laser & Surgery Center of El Paso
1700 N. Oregon, Suite 765, El Paso, TX 79902 (915) 543-5600
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Stanton Street Technology Group
Cosmetic Fee Plan is a flexible monthly payment option offered through AmeriFee. It is specifically designed for cosmetic surgery - with payments as low as $99 per month.
  • No down Payment
  • Low, fixed rates ranging from 9.99% - 13.99%
  • No prepayment penalty
We offer payment plans from CareCredit® Apply Now

CareCredit for cosmetic procedures

CareCredit® Apply Now

We're pleased to offer our patients the CareCredit® card, North America's leading patient payment program. The CareCredit card is just as easy to use as a regular credit card, but it's designed specifically for your health and beauty needs. Best of all, CareCredit offers convenient payment plans and no hidden costs. You can even use your CareCredit card over and over for follow-up appointments. Apply now or to learn more about CareCredit, please contact us.