Patient Forms

In order to understand you better, we request that you complete a few forms.  Ideally these can be completed before your first visit with us.  They provide information to us about your health, your concerns, and what you hope to achieve.  Please review the appropriate forms, print and sign them and bring them with you to your visit.  Doing this will save you some time in the office.  If you are unable to complete the forms before your first visit, that’s okay.  We will have you complete them when you arrive.

The forms we require depend on the nature of your visit.  Please look through the sections listed below.  Find the section or sections that apply to you and the reason(s) for your visit.  If you are going to consult with Dr. Kunkel about breast augmentation, for instance, look in the section titled “Cosmetic Breast Surgery Patient Forms”.  Similarly, if you are a breast cancer patient, look in the section titled “Reconstructive Breast Surgery Patient Forms”.    Finally, if you are going to see Dr. Kunkel about a few issues in different areas, just look in the appropriate sections and complete the forms that apply.  If you are filling out forms from more than one section, you only need to complete the HIPAA consent form once.

Cosmetic Breast Surgery Patient forms

If you are considering undergoing breast augmentation, breast lift, removal of breast implants, a mommy makeover, or revision of previous cosmetic breast surgery, please read and complete the forms listed here.

• Notice of Privacy Practices (HIPAA)  – Please read this form; no signature is required.
• HIPAA Consent – Please print and sign this form.  This acknowledges that you have received a copy of the HIPAA form and have read it.
• Cosmetic Breast Surgery Patient Information Form  – Print and fill out this form.

Reconstructive breast surgery patient forms

If you are thinking about undergoing reconstructive breast surgery that may be covered by insurance, please read and complete the forms listed in this section.  Examples of these types of procedures include breast cancer reconstruction, some breast reductions, and some cases of ruptured silicone gel breast implants.

• Notice of Privacy Practices (HIPAA) – Please read this form.  No signature is required
• HIPAA Consent – Please print and sign this form.  This acknowledges that you have received a copy of the HIPAA form and have read it.
• Reconstructive Breast Surgery Patient Information Form  – Print and fill out this form as well.

body contour surgery patient forms

Please read, print, and fill out the following forms if you are considering tummy tuck, liposuction, body lift, arm lift, thigh lift, or mommy makeover surgery.

• Notice of Privacy Practices (HIPAA)  – Please read this form.  No signature is required.
• HIPAA Consent – Print and sign this form.  This acknowledges that you have received a copy of the HIPAA form and have read it.
• Health Information Form  – Print and fill out this form as well.  This form tells us about your health in general.
• Body Contour Surgery Questions  – Please also print and fill out this form.  It is more specific to body contour concerns.

Facial surgery patient forms

The following forms apply if you are considering facelift, eyelid (blepharoplasty), nasal (rhinoplasty), and ear (otoplasty) surgery.

• Notice of Privacy Practices (HIPAA) – Please read this form; no signature is required.
• HIPAA Consent – Print and sign this form.  It acknowledges that you have received a copy of the HIPAA form and have read it.
• Health Information Form – Print and fill out this form please.  It provides us with information about your health.