Patient Forms and Guidlines

 

Patient Medical History



   

Section 1
Patient History: Check all that apply to your current health as well as your past medical history.



Section 2
Female Only: Please check all that apply to you current or past medical history.





Section 3
Please list the month and year of the most recent year you have had these tests performed.


















 

 

 



Section 4




Quality of Life Assessment





Copy of Government ID

Please Make a Copy of Picture Identification


Practice Boost requires a patient to supply our medical practice with a copy of a valid state identification or U.S Passport before they may begin a therapy program. A failure to supply Practice Boost with identification will automatically disqualify a prospective patient from receiving treatment.


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Credit Card Payment Authorization Form



        










Patient Consent for the Use & Disclosure of Health Information







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Pisarski MD

Gregory P. Pisarski, MD

Pisarski MD

My philosophy is to provide my patients with the highest level of medical care available in an ethical and confidential manner. I strive to stay current with the most advanced technology in cosmetic enhancement procedures. We'll help educate you about your options, so you can feel confident about your decision.

Pisarski MD

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Pisarski MD
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Pisarski MD