header Tampa Bay Plastic Surgery



To schedule an appointment, please call:
Plastic Surgery Office - (813) 400-1949
Med Spa Office - (813) 739-0915

Patient Registration



New patients, please completely fill out the following form. Note: All fields marked with an asterik* are required

Patient Information

Patient's Name*
Parent's Name (minors only)
Street Address*
City*
State*
ZIP*
Home Phone*
Cell Phone
Email Address
Birth Date (MM/DD/YYYY)*
Sex*
May we leave voice mails at the
provided telephone nuumbers?*
If so, which number do you prefer?*
May we send emails (i.e. appointment reminders, product and service offerings?)*
How Did You Hear About Us?*

Scheduling Appointment

Reason for Visit (please check all that apply)
Do you already have an appt?*
Preferred Appointment Day:
Preferred Appointment Time:

Insurance Information

Insurance Coverage
Insurance Company
Member #
Group #
Social Security #
Name of Insured
Card Holder's DOB (if different
than Patient) MM/DD/YYYY
SS of Card Holder

Cosmetic Surgery - Breast Procedures

Cosmetic Surgery - Body Procedures
 

Cosmetic Surgery - Facial Rejuventation
 

Other Procedures

Insurance Procedures

Questions & Comments

IMPORTANT!* Dr. Aguiar doesn't operate on "robots" so if you are a "human" please answer this simple math problem. 7+3=?



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