Cosmetic Patients

Forms to Download & Complete

Please follow the steps below and use the links on the left for the New Patient "Express" Check-in.

The following steps need to be completed 48 hours in advance of your appointment time.

1st STEP
1) Print, complete and sign PATIENT PROFILE
2) Print and complete COSMETIC PROFILE
3) Print, complete and sign PHOTO CONSENT
4) Print HIPAA ACKNOWLEDGMENT -  please complete and sign top portion of HIPAA Acknowledgment if you want a copy of the HIPAA policy or complete and sign the bottom portion of HIPAA Acknowledgment if you are declining a copy of the HIPAA policy
5) Print HIPAA POLICY, if applicable - this is for your records only. It is not necessary for you to bring with you to our office or send back to our office.

2nd STEP
1) Fax all of the above documents to (816) 554-9470
                        OR
2) E-mail all of the above documents to: newpatient@summitskinandveincare.com
                        OR
3) Mail to us at: 3521 NE Ralph Powell Rd, Ste C, Lee's Summit, MO  64064

3rd STEP
Arrive 5 minutes prior to appointment time to check-in

THANK YOU FOR USING EXPRESS CHECK-IN