Patient Forms

Please click on the links below to print out and complete all 3 forms and bring them with you to your appointment.

 

Health History
Contact Information
Patient Registration Form

Please note that there is a $100 fee for a personal consultation with Dr. Norris. When you make your appointment we will ask for a credit card number but will not charge your credit card until you arrive for your appointment. We require a 24 hour cancellation notice. If you do not give our office 24 hour notice of your cancellation we will charge your credit card a $100 no-show fee. The cost of your personal consultation, $100, is deducted from the cost of your surgical procedure when you schedule your procedure with Dr. Norris.

WHY DOES DR. NORRIS CHARGE FOR A PERSONAL CONSULTATION?

We charge for a personal consultation because Dr. Norris' time is very valuable and he meets PERSONALLY with every patient. He realizes as well that your time and money are valuable and offers personalized service for every patient as well as a customized and detailed plan.

Dr. Norris will not rush you and will spend time tailoring a plan specifically for you that will ultimately give you the results that you desire. He will answer all of your questions and both he and his patient coordinator will be available to you by phone or email for any follow-up questions you may have after your consultation.

Which procedures or services are you interested in?
(check all that apply)

	Facelift		Necklift		Browlift
	Eyelid Surgery		Lip Augmentation		Botox Injections
	Breast Augmentation		Breast Lift		Breast Reduction
	Male Breast Reduction		Liposuction		Tummy Tuck
	Skin Care		Skin Peels		Facial Fillers
	Patient Financing
	Other (please specify below)

Please enter any additional services or questions you may have:

First Name:

Last Name:

Street Address:

City:

State:

Zip:

Phone:

home   work   cellular

your e-mail address:

Preferred method of contact:
phone mail e-mail

How did you find our web site?

	Search engine		Saw address in ad
	PlasticSurgery.org (American Society of Plastic Surgeons)
	Other:

e-mail: pssnorrismd@sbcglobal.net

Driving Directions: www.mapquest.com

Michael Norris M.D. • Plastic Surgery
1860 El Camino Real Suite 438, Burlingame, California 94010
Telephone: 650.652.5901 • Fax: 650.652.5904