Gregory G. Gion, MMS, CCA
Allison K. Vest, MS, CCA
Certified Clinical Anaplastologists
214-363-2055 (Southern Office)
608-833-7002 (Midwest Office)

New Patient Forms


If you’d like to get a head start on your new patient paperwork, you can download the forms below.

Please use as much detail as possible completing the forms. Don’t worry if you can’t fill in all the blanks – we’ll review the forms with you during your consultation.

To download the forms to your computer:

  • Right-click the form link below
  • Choose “Save Target As” or “Save Link As” from the popup menu
  • Save the forms to your Desktop
Form... Please...
Combined Privacy Notice Read and sign
Patient Registration Form
Patient Registration Form (Spanish)
Read and complete
Prior Medical History Form Read and complete
Photo Consent Read and sign
Return Policy Read and keep