DALLAS-FORT WORTH INSTITUTE OF BODY SCULPTURING

PATIENT REGISTRATION

Fill out the application, print, sign and fax to:  972-602-0613

Or mail to:  
Dallas-Fort Worth Institute of Body Sculpturing
647 S. Great Southwest Pkwy., Suite 105
Grand Prairie, TX  75051

Please fill out both the Patient Registration form and the Patient Health Questionnaire.

If you have questions about the application, please e-mail  drwalteradobson@swbell.net

 
NAME
First Name
Middle Initial
Last Name
HOME
 ADDRESS

City
State
Zip Code
PHONE NUMBERS

Home Phone
Work Phone

Cell Phone 		 
EMAIL
E-mail
PERSONAL
INFORMATION

Date of Birth
Age
Social Security #

Employer/Occupation		  
 
EMERGENCY
CONTACTS

Spouse Name

Spouse Work Phone
Spouse Home Phone

Closest Relative

Relative's Work Phone 		 
Relative's Home Phone
How did you hear about Dr. Dobson? (Check all that apply)

Internet
Fort Worth Star Telegram newspaper
Texas Monthly
Health & Fitness
D Magazine
Radio
TV
Yellow Pages
RSVP/Mail
Fort Worth, Texas
Dallas Morning News
Family/Friend Name:

What improvements are you seeking?

Why is this important to you?

Have you discussed this with your (check as many as apply):

Spouse
Family
Friends

Their opinion was:

Supportive
Uncommitted
Against It
Have you had a prior consultation with another doctor?   Yes   No

If yes, with whom? 

Have you had any other cosmetic surgery procedures?  Yes   No

If yes, type of procedure: 

If yes, name of surgeon:
What (if any) are your concerns about this procedure?

When are you planning to have your procedure done?
  ASAP     1-3 weeks       4-8 weeks     2-6 months     unsure
  How will you pay for the services rendered?
Cash   M/C   Visa   American Express   Financing   Other
This information is accurate and true to the best of my knowledge.

Patient Signature: 
                  Date: 

Please Print, Sign and Fax or Mail this form.  Contact information located at top of this page.  Then, please fill out the Patient Health Questionnaire.