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  • About
    • Meet The Doctor & Staff
    • Service Areas
  • Procedures
    • Breast
      • Breast Augmentation
      • Breast Lift
      • Breast Reduction
      • Breast Reduction and Lift
      • Gynecomastia
      • Prophylactic Mastectomy
    • Breast Reconstruction
      • Areola Reconstruction
      • BRCA Mastectomy Reconstruction
      • Breast Reconstruction
      • Delayed Breast Reconstruction
      • DIEP Flap Reconstruction
      • Double Mastectomy Reconstruction
      • Nipple Reconstruction
      • Prepectoral Breast Reconstruction
      • Revision Breast Reconstruction
      • Skin Sparing Mastectomy
      • Nipple Sparing Mastectomy
    • Body
      • Liposuction
      • Abdominoplasty
      • Body Lift
      • Body Contouring
    • Face
      • Non-Invasive Facial Treatment
      • Profound Radiofrequency
      • Facial Plastic Surgery
      • Precision Rhinoplasty
    • Mohs Surgery Reconstruction
    • Mommy Makeover
  • Before & After
    • Breast Cosmetic
    • Breast Reduction
    • Breast Reconstruction
    • Prophylactic Mastectomy
    • Tummy Tuck
    • Mommy Makeover
  • Testimonials
    • Reviews
  • Resources
    • New Patient Forms
    • Educational Videos
    • NYSHIP Empire Plan Breast Reduction Coverage
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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
  • 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

Forms for New Cosmetic Patients

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

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500 Montauk Hwy Suite H
West Islip, NY 11795

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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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