• MiBella Male Review of Health History Patient Forms

  •  - -
    Pick a Date
  • Primary Insurance

  •  - -
    Pick a Date
  • Review of Health History for Men

  •  - -
    Pick a Date
  • Review of Symptoms and History for Men

    Please provide complete information so we can better serve you.
  • Fees for No-Shows, Cancellations, Rescheduling of Surgery and Other Fees

  • To better serve our patients and ensure the availability of appointments, the following policy is necessary: There will be a charge if you fail to cancel your scheduled appointment (24) hours prior to your appointment time. If your appointment is on a Monday, please call the Friday before your scheduled appointment to cancel or reschedule to avoid the cancellation fee.

    For frequent missed appointments, we may require a non-refundable and non-transferable deposit for all future appointments. Your credit card on file will be billed  on the day of your visit if you fail to cancel your appointment 24 hours prior to the scheduled time. In the event, no credit card is on file, you will be billed the  cancellation fee, which must be paid prior to any future appointments.

    If you are more than 15 minutes late for your appointment it is equivalent to a No-Show. You will be charged or billed and will have to reschedule your appointment.

    A (48) hour notice is required for all surgery cancellations. Cancellations with less than (48) hour notice, will be charged a fee.

    Other Fees: There is a $25 charge for all forms, letters, FMLA forms, etc. and a $25 plus for copying of medical records.

  • Clear
  •  - -
    Pick a Date
  • Driver's License and Insurance Images

    Zoom In On All Photos
  • Should be Empty: