Welcome to Bronx Plastic Surgery’s patient forms.
All patients must complete these forms prior to their first scheduled appointment. Please review and download these forms. Should you have any questions about how to access or fill out the forms, please contact us at (718) 405-7500.
Completing these patient forms prior to your visit will help speed up the registration process. Click on the title to download.
Medical History Form
This form provides us with information about your health history. If you have an appointment with one of our doctors, please fill out this form and bring it with you to your first appointment to save you time in the office. (Historial Médico En Español)
Patient Information Form
This form provides us with information about you, your insurance, and specifics about the nature of your injury or condition. Fill out this form and bring it with you to your first appointment to save you time in the office. (Hojas De Información Del Paciente En Español)
Insurance Coverage Form
Please read the Insurance Coverage Form prior to your first visit. This form helps to answer questions about Insurance coverage and patient responsibility.Please read carefully as your coverage may have varying benefits and requirements. Fill out this form and bring it with you to your first appointment to save you time in the office. (Hoja de Cobertura de Seguro En Español)
Confidentiality Policy Statement
Please print and complete the Confidentiality Policy Statement prior to your first visit. The purpose of this Confidentiality Policy Statement is to ensure that everyone working with and under the supervision of Dr. Robert Goldstein is aware of his or her responsibilities when using the Protected Health Information (PHI) of Patients.(Politica De Confidencialidad En Español)
Receipt of Notice of Privacy Practices
By signing this form, you acknowledge receipt of the Notice of Privacy Practices from the Bronx Plastic Surgery PLLC, Robert D. Goldstein, MD. The Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to review it carefully. The Notice of Privacy Practices is subject to change. If the Notice is changed, you may obtain a revised copy here or by sending a request to our staff. Fill out this form and bring it with you to your first appointment to save you time in the office.