INFO@BEAUTYRPS.COM
(760) 537-3023
74000 Country Club Dr, Suite A2, Palm Desert, CA
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Surgical Procedures
Nose
Rhinoplasty
Face
Otoplasty
Face Lift Neck Lift
Filler Injectables
Blepharoplasty Eyelid Surgery
Facelift
Brow Lift | Forehead Lift
Body
Body Contouring
Tummy Tuck
Brazilian Butt Lift BBL
Body Sculpting
Hair Restoration
Breast Augmentation
Breast Revision
Gynecomastia Breast Reduction
Breast Reconstruction
Veins
Vein Surgery
Non-Surgical
Face
Non Invasive Laser Facelift
Hydrafacial
Microneedling
Body
Laser Hair Removal
Skin
Laser Tattoo Removal
Laser Skin Rejuvenation
Laser Acne And Acne Scar Treatment
Thread Lifts PDO
Coolpeel
Treated Conditions
Acne
Acne Scars
Age Spots
Aging Face
Aging Hands
Broken Capillaries
Cellulite
Dark Circles Under Eyes
Facial Wrinkles
Jowls
Loose Skin
Migraines and Headaches
Nasal Bumps and Deviations
Pearly Penile Papules (Hirsutoid papillomas)
Premature Hair Loss
Rosacea and Skin Pigmentation
Self Harm Scar Revision
Square or Full Jawline
Sweaty Palms
Thin Lips
Vaginal Laxity
Weak Chin
Wrinkled Lips
Weak Jaw
Hip & Butt
Before- After Gallery
Blog
Patient Forms
Covid-19 Risk Informed Consent
Conditions of Treatment
Registration Form
MENU
MENU
Home
About
Contact Us
Surgical Procedures
Nose
Rhinoplasty
Face
Otoplasty
Face Lift Neck Lift
Filler Injectables
Blepharoplasty Eyelid Surgery
Facelift
Brow Lift | Forehead Lift
Body
Body Contouring
Tummy Tuck
Brazilian Butt Lift BBL
Body Sculpting
Hair Restoration
Breast Augmentation
Breast Revision
Gynecomastia Breast Reduction
Breast Reconstruction
Veins
Vein Surgery
Non-Surgical
Face
Non Invasive Laser Facelift
Hydrafacial
Microneedling
Body
Laser Hair Removal
Skin
Laser Tattoo Removal
Laser Skin Rejuvenation
Laser Acne And Acne Scar Treatment
Thread Lifts PDO
Coolpeel
Treated Conditions
Acne
Acne Scars
Age Spots
Aging Face
Aging Hands
Broken Capillaries
Cellulite
Dark Circles Under Eyes
Facial Wrinkles
Jowls
Loose Skin
Migraines and Headaches
Nasal Bumps and Deviations
Pearly Penile Papules (Hirsutoid papillomas)
Premature Hair Loss
Rosacea and Skin Pigmentation
Self Harm Scar Revision
Square or Full Jawline
Sweaty Palms
Thin Lips
Vaginal Laxity
Weak Chin
Wrinkled Lips
Weak Jaw
Hip & Butt
Before- After Gallery
Blog
Patient Forms
Covid-19 Risk Informed Consent
Conditions of Treatment
Registration Form
REGISTRATION FORM
Registration Form
Beauty Refined Plastic Surgery
Prefix
Mr.
Mrs.
Ms.
Miss
First Name
Last Name
Marital Status
Married
Single
Divorced
Separated
Widowed
Is this your legal name?
Yes
No
If not, what is your legal name?
What is your former name?
Gender
Male
Female
Date of Birth
Age:
Social Security
Street Address line 1
Street Address line 2
City
State
Zip Code
Phone
Email
I chose this clinic because:
of the Doctor
the Hospital
A friend recommended it
Internet
Insurance plan
Family
Close to my home/work
Work:
Full-time
Part-time
Retired
Student
Unemployed
Occupation
Employer
Employer Phone
Do you use alcohol?
Yes
No
How many drinks per week?
Do you use drugs for non-medical purposes?
Yes
No
Do you use nicotine/tobacco?
Yes
No
How much, How long?
HAVE YOU EXPERIENCED ANY OF THE FOLLOWING SYMPTOMS IN THE LAST MONTH?
Fever
Chills
Heavy Sweating/Night Sweats
Loss of Appetite
Sleep Disturbances
Unexpected Weight Loss/Gain
Blurry Vision
Double Vision
Depression
Anxiety
Sore Throat
Mouth Sores
Nasal Congestion/Sinus Issues
Hearing Loss
Chest Pain or Discomfort
Swelling Feet, Ankles, Legs
Heart Attack
Irregular Heartbeat
Palpitations
Varicose Veins
Painful Urination
Frequent Urination
Incontinence
Skin Rash
Skin Itching
Discoloration
Lumps of Masses
Cough
COPD
Wheezing
Recurrent Respiratory Infections
Shortness of Breath
Abdominal Pain
Nausea/Vomiting
Indigestion/Heartburn
Bloody Stools
Change in Bowel Habits
Rectal Bleeding
Diarrhea
Constipation
Swallowing Difficulties
Joint Pain
Joint Swelling
Back Pain
Neck Pain
Limitation of Motion
HAVE YOU EXPERIENCED ANY OTHER SYMPTOMS NOT LISTED ABOVE?
ARE YOU INTERESTED IN LEARNING ABOUT ADDITIONAL TREATMENTS AND/OR PROCEDURES?
Yes
No
Which Ones?
Botox/Fillers
Cool Sculpting
Liposuction/Tummy Tuck
Eyelid Procedures
Skin Tightening
Skincare
Breast Augmentation
Other:
INSURANCE INFORMATION: Primary Insurance
Medicare
Other
Subscriber’s S.S. Number:
Birth Date:
Group No.
Policy No.
Co-payment
Patient’s relationship to subscriber:
Self
Spouse
Child
Other
Name of secondary insurance (if applicable):
Subscriber’s name:
Group No.
Policy No.
Patient’s relationship to subscriber:
Self
Spouse
Child
Other
IN CASE OF EMERGENCY: Name of local friend or relative (not living at same address):
Relationship to patient:
Phone Number:
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Beauty Refined Plastic Surgery or insurance company to release any information required to process my claims.
Patient/Guardian signature:
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