RESOURCES

Patient Resources

Our staff looks forward to meeting you and discussing your cosmetic surgery goals. We strive to keep our appointments on time, as scheduled. Our patient history forms are available for download (pdf). It is very important that Dr. Brackup understands your complete health history prior to scheduling any procedures. In order to save time during your office visit, please print the form, fill out as completely as possible, and bring it with you to the office. If you are unable to download our patient forms, then it is recommended that you arrive to your appointment between 15-30 minutes early so that you can have ample time to fill out the appropriate forms. This history form includes questions regarding other medical conditions, previous surgery, current medications, and allergies. The history form also contains a place for emergency contact information and basic demographics. We also have a copy of our HIPAA privacy form to be signed and brought with you to your scheduled appointment.

Please note that all of your information is kept strictly confidential, and our office complies with existing protected health information and HIPAA guidelines.

HIPAA Privacy Form

HIPAA Privacy Form

Notice of Privacy Practices for Cosmetic Surgery Specialists

Cosmetic Patient History

Cosmetic Patient History

Patient Medical History Forms for Cosmetic Procedures

Medical Patient History

Medical Patient History

Patient Medical History Forms for Medical Procedures

*Individual results are not guaranteed and may vary from person to person. Images may contain models.