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Menu
  • About
    • Meet The Doctor & Staff
  • Procedures
    • Breast
      • Breast Augmentation
      • Breast Lift
      • Breast Reduction
      • Male Breast Reduction
    • Body
      • Liposuction
      • Abdominoplasty
      • Body Lift
    • Face
      • Nonsurgical Facelift
        • Botox/Jeuveau/Dysport
        • Soft Tissue Fillers
        • Facial Fat Grafting
      • Profound
      • Surgical Facial
        • Facelift
        • Neck Lift
        • Forehead Lift (Brow Lift)
        • Eyelid Surgery
      • Precision Rhinoplasty
    • Breast Reconstruction
      • General Concepts
      • Implant Breast Reconstruction
      • Tissue Based Breast Reconstruction
      • Revision Breast Reconstruction
        • Problem Based Solutions
        • Prepectoral Revision Reconstruction
    • Mohs Surgery Reconstruction
  • Before & After
    • Breast Cosmetic
    • Breast Reduction
    • Breast Reconstruction
  • Testimonials
  • Resources
    • New Patient Forms
    • Educational Videos
Contact

RESOURCES

New Patient Forms

On this page you will find printable forms for New Insurance and New Cosmetic Patients. To enhance your experience and make the entire process as smooth as possible, please fill out these forms prior to your consultation and email them back to info@harrisplasticsurgery.com.

Forms for New Insurance Patients

  • New Patient Form
  • History and Physical
  • Out of Network Disclosure Law
  • Assignment of Benefits
  • NY Emergency Medical Services
  • Member Authorization Form for a Designated Representative to Appeal a Determination
  • Protected Health Info Authorization
  • Consent to Use Protected Health Info Authorization
  • Non-Medicare Authorization
  • Notice of Privacy Practices

Forms for New Cosmetic Patients

  • New Patient Form
  • History and Physical
  • Financial Consent for Cosmetic Surgery
  • Out of Network Disclosure Law
  • NY Emergency Medical Services
  • Protected Health Info Authorization
  • Consent to Use Protected Health Info Authorization
  • Non-Medicare Authorization
  • Notice of Privacy Practices

We look forward to helping you achieve your ideal result. Please contact us or call us with any questions.

CONTACT

Our Office

Contact Us

500 Montauk Hwy Suite H
West Islip, NY 11795
631.422.9100

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About / Testimonials

  • Meet the Staff
  • #cosmeticsurgery
  • Testimonials

Resources

  • New Patient Forms
  • Educational Videos
  • Blog

Face

Nonsurgical Facelift

  • Botox/Dysport/Xeomin
  • Soft Tissue Filters
  • Facial Fat Crafting

Surgical Facial

  • Facelift
  • Neck Lift
  • Forehead Lift (Brown Lift)
  • Eyelid Surgery

Additional Face Procedures

  • Profound
  • Rhinoplasty

Additional Procedures

  • Moh's Surgery Reconstruction

Procedures

Breast

  • Trufit Breast Enhancement Process
  • Breast Augmentation
  • Breast Lift
  • Breast Reduction
  • Male Breast Reduction

Body

  • Liposuction
  • Abdominoplasty
  • Body Lift

Breast Reconstruction

  • Central Concepts
  • Implant Breast Reconstruction
  • Tissue Based Breast Reconstruction

Revision Breast Reconstruction

  • Problem Based Solutions
  • Prepectoral Revision Reconstruction

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