New Patient Forms

As a new patient being seen for a reconstructive or cosmetic service, please arrive at our office 20 minutes in advance of your appointment to register. Please bring with you your medication list, insurance card, drivers license, and a form of payment, if applicable. If you are a new patient being seen at our Skin Care Center, please fill out the new patient form for the Skin Care Center (linked below). Arrive 20 minutes prior to your appointment to finish the registration process. Along with your completed forms, please bring a form of payment.

For your convenience, the following Patient Forms are available for downloading and printing:

New Patient Forms - Skin Care Center Services
When you are going to be seeing our Skin Care Specialist for the first time - or if it has been longer than three years since you saw her last.

New Patient Forms - Cosmetic Services
When you are going to be seeing one of our plastic surgeons for the first time - or if it has been longer than three years since you last saw one of them - to discuss a cosmetic procedure that is not paid for by insurance companies. (breast augmentation, tummy tuck, etc.)

New Patient Forms – Reconstructive (medically necessary services)
When you are going to be seeing one of our plastic surgeons for the first time - or if it has been longer than three years since you last saw one of them - to discuss a procedure that will be billed to your insurance company. (breast reduction, breast reconstruction, lesion removal, hand surgery, etc.)

New Patient Forms - HIPAA Notice of Privacy Practices

Effective April 9, 2014, Northland Plastic Surgery is implementing a new registration process called Phreesia. This new registration process will allow reconstructive and cosmetic patients to fill out their information on a tablet in our office. Please arrive 20 minutes in advance of your appointment to register. New patients for our Skin Care Center will still register by printing and completing the forms above.

You may submit your patient information in any of the following ways:

  1. Download and print the forms. Complete them and bring them with you on the day of your appointment. Please arrive 20 minutes in advance of your appointment to finish registering at our office.
  2. Download and print the forms. Complete them and return to our office one of two ways. You may mail them to our office at 1420 London Road, Suite 101, Duluth, MN 55805 or fax to us at 218-724-6199.
  3. Request that the forms to be mailed to you (while on the phone with us scheduling your appointment). Complete them and bring them with you on the day of your appointment. Please arrive 20 minutes in advance of your appointment to finish registering at our office.

AUTHORIZATION FOR RELEASE OF CONFIDENTAL MEDICAL INFORMATION:
Download/Print
If you need a copy of your medical records from us, please print out and mail in this form.

Call us with your requests and any additional questions at 

(218) 724-7363 or (800) 964-6891

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  • SkinCare6
  • Mixed8
  • Reconstructive5
  • "I can move better than before. My legs have more flexibility and it is easier to walk. These procedures have been very effective - they have made me happier and my scars look better than ever." ~ Ashley
  • "My experiences at Northland Plastic Surgery have been very positive. They have gone above and beyond to make sure I always received the necessary treatments." ~ Candy
  • "The surgery effectively removed the folds of my eyelids which had impaired my vision. Northland Plastic Surgery is an immaculate facility with efficient and friendly staff. I will recommend NPS to others." ~ Richard