Date(Required)

Date of Birth(Required)

Email Address(Required)

Procedures/Pricing Requested(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

Alternate Phone Number

Preferred Method of Contact

Preferred Time to Contact

Marital Status

If Student, Name of School/If Working - Job Description, Full or Part Time

Emergency Contact(Required)

May we discuss your surgery or treatment with this contact? If not, then let us know whom to call if there is an emergency.(Required)

Yes

I will tell you when I get there

Can we send you emails and newsletters including our famous "Monthly Specials" and "Flash Specials"(Required)

Yes

Can we send you appointment reminders via email and text?(Required)

Yes

Email Only

Text Only

May we text you about Specials/Deals/Flash Sales? We also use text to communicate!(Required)

Yes

Just communicate

How did you hear about us?(Required)

Describe how you heard about us!

Are you hydrated? (Drinking 6-8 glasses of water a day)

Have you taken an Antibiotic in the last 7 days?

If on Antibiotic or any other new medication please list them here in full.

Please list any new health issues.

Any topical creams or skin prescriptions in the last month or up to one year (Especially Tretinoin, Retinols Prescription Acne)

Any NSAIDS(ibuprofen, advil, anaprox, or any others) or Aspirin in last 7 days

Yes

Are you suffering from Herpes Simplex 1 or 2 (cold sores/zoster or gential sores)

Yes

I am being treated and will let you know

Have you recently had Sun Exposure or are using Sun Tanning Beds

Do You Have a Patient Coordinator Yet?(Required)

Yes

If no, we will assign you one.

If Yes, Which Coordinator Have You Spoken With?

Please open and acknowledge that you read our Terms of Service and Privacy Policies!

Dr. Jeneby Plastic Surgery - Terms and Conditions & SpaBlack - Terms and Conditions

The Office is an elective surgical office and spa and therefore, we do not accept insurance of any kind. FMLA Leave is generally not available for purely Cosmetic Procedures. We do not guarantee employer approval for FMLA nor do we falsify documents. There is a 25$ fee , per individual request, before completing FMLA paperwork. We require two weeks notice for FMLA Paperwork. We do not guarantee 2 weeks. When submitting FMLA, please complete your portion of the paperwork first. (work duties, amount of time off)

I understand all sales are final. I am responsible for all bills being paid in a timely manner. I understand that this contract is between Plastic and Cosmetic Center, Trilogy by Jeneby (DBA Spa Black) and me.

The information you provide is confidential and is only to be used at Spa Black and The Cosmetic Center of South Texas.

Prepay for your consult 75$ or pay your surgery/spa procedure in full (if credit cards allowed) debit cards may need pre-authorization from the bank.

This field is for validation purposes and should be left unchanged.

Patient Demographics Form

Spa Black

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Patient Demographics Form