Patient Information

Patient Registration

Please plan to arrive about 15 minutes early for your first visit so that we can complete your paperwork. To save time, you may download and print all necessary forms for your appointment.

Patient’s Name

Patient’s Address

Patient’s Contact


Patient’s Information


SingleMarried to:Other:


Patient’s Employer


Patient’s Employer Address

Emergency Contact (Not in your household)

Emergency Contact's Address

Referral Program We reward those who refer our services to others!

Computer Image Analysis

For your benefit, we provide a computerized image analysis to help you visualize what changes might be possible through cosmetic surgery. The outcome of any surgical procedure is highly dependent on the individual patient. Since there are significant differences in how live tissue reacts to surgery – and how it heals – the results are not predictable. Therefore, be advised that this analysis is provided for purposes of illustration only and that no guarantees are made as to the specific outcome of any particular surgical procedure. Any such warranties, express or implied, are hereby waived by the physician and the patient hereby indemnifies and holds harmless the physician, staff, and clinic.

Fee for Service

Although services under particular circumstances may be covered under my insurance plan, I understand that I am fully
responsible for payment at time of service:

Request a Consultation
Naperville Magazine- Best of Naperville Winner 2015-2016.

Center For Cosmetic and Laser Surgery in Naperville & Chicago, IL
Best of Naperville 2010-2018

1331 W 75th St. #306
Naperville, IL 60540

(630) 851-3223
[email protected]

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