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Complete New Patient Form Online

Home » New Patient Forms » Complete New Patient Form Online

BEAUTY BY DESIGN

ROBERT J. TROELL, M.D., F.A.C.S.

Are you a new patient? We would like to thank you for selecting Beauty By Design for your beauty, cosmetic, and body sculpting needs. Please complete this online form below, which is divided in three easy steps. Then, you will be prompted to suggest a date/time for your consult.

  • Patient Information

  • MM slash DD slash YYYY
  • Emergency Contact

  • I SWEAR THAT THE MEDICAL & DEMOGRAPHIC INFORMATION PROVIDED IS TRUE. I HEAREBY AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NEEDED TO PROCESS ANY INSURANCE CLAIM, MY MEDICAL INSURANCE BENEFITS ARE TO BE PAID DIRECTLY TO DR.TROELL, AND I AGREE TO PAY FOR ALL CHARGES NOT PAID BY MY INSURANCE COMPANY45 DAYS AFTER BILLED. IN THE EVENT THIS ACCOUNT IS REFERRED TO AN ATTORNEY OR COLLECTION AGENCY FOR COLLECTION, I AGREE TO PAY REASONABLE ATTORNEY’S FEES. OR ANY 3RD PARTY FEES & COURT COSTS FOR COLLECTIONS. THERE WILL BE A 5% PROCESSING FEE ADDED TO ANY PAYMENT USING FINANCE COMPANIES.
  • Medical History PSI

  • In the following questions, please Circle YES or NO, & Circle the item that you HAVE:

  • 3. Do you have or have you had any of the following medical problems?
  • Cosmetic Patient Registration

  • Please let us know how you were referred to our practice (circle item):
  • Provider Notice of Privacy Practices

  • This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review carefully

    We use health information about you for treatment, to obtain payment for treatment, administrative purposes, and to elevate the quality of care you receive. Continuity of care is part of treatment and your records may be shared with other providers to whom you are referred. Information may be shared by paper mail, electronic mail, text messaging, fax or other methods.

    We may use or disclose identifiable health information about you without your authorization for several reasons. Subject to certain requirements, for auditing purposes, for research studies, and for emergencies. We provide information when otherwise required by law, such as for the law enforcement in specific circumstances. In any other situation we will ask you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any further uses and disclosure.

    We may change our policies at any time before we make a significant change in our policies, we will change our notice and post the new notice in the waiting area. You can request a copy

    Individual Rights In most cases you have the right to look or get a copy of health information about you that was used to make decisions about you. If you request copies we will charge you only normal photocopy fees ($0.60 per sheet), available in 2 weeks from date of request. You may also have the right to receive a list of instances where we have disclosed health information about you for reasons other than treatment, payment or related administrative purposes and other than when you explicitly authorized it. If you believe that information in your record is incorrect or if important is missing, you have the right to request that we correct the existing information or add the missing.

    Complaints If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact our office. You may also send a written complaint to the U.S. Department of Health and Human Service.

    Our Legal Duty We are required by law to protect privacy of your information provide this notice about our information practices, follow the information practices described in this notice, and obtain your acknowledgement to receipt of this notice.

  • I CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT AND ACCURATE.

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

FACE

Facial Cosmetic Surgery.

Face

BODY

Body Plastic Surgery. Body Contouring.

Face

SKIN

Skin Treatments, including Bellafill®

Face

ANTI-AGING

Stem Cell Therapy and other Anti-Aging programs.

FACE

Face Procedures

Facial Cosmetic Surgery.

BODY

Body Procedures

Skin Treatments, including Bellafill®

BREAST

Breast Procedures

Implants. Augmentation. Reduction. And more!

ANTI-AGING

Anti-Aging Procedures

Anti-Aging programs.

Robert J. Troell, M.D., F.A.C.S. at Corona Del Mar, New Port Beach, CA

BEAUTY BY DESIGN New Port Beach: A REGENERATIVE MEDICAL SPA IN Corona Del Mar, CA.

Beauty By Design in Las Vegas is not the only location where you can meet Dr. Troell. Robert J. Troell, .M.D., F.A.C.S. is also serving clients in Corona Del Mar, New Port Beach, California. Learn more about Beauty By Design Corona Del Mar, or call (949) 220-0532.

Two Locations to Better Serve You

Las Vegas

Robert J. Troell, M.D., F.A.C.S. (Las Vegas, Nevada)

Robert J. Troell, M.D., F.A.C.S.
(Las Vegas, Nevada)

Address: 5375 S Fort Apache Rd
Suite 101
Las Vegas, NV 89148.
Phone: (702) 242-6488

Driving Directions Contact Us

New Port Beach

Robert J. Troell, M.D., F.A.C.S. (New Port Beach, California)

Robert J. Troell, M.D., F.A.C.S.
(New Port Beach, California)

Address: 2801 East Coast Hwy
Suite E
Corona del Mar, New Port Beach, CA 92625.
Phone: (949) 220-0532

Driving Directions Contact Us
  • Las Vegas
  • Corona del Mar

Las Vegas

Robert J. Troell, M.D., F.A.C.S. (Las Vegas, Nevada)

Robert J. Troell, M.D., F.A.C.S.
(Las Vegas, Nevada)

Address: 5375 S Fort Apache Rd
Suite 101
Las Vegas, NV 89148.
Phone: (702) 242-6488

Driving Directions Contact Us

New Port Beach

Robert J. Troell, M.D., F.A.C.S. (New Port Beach, California)

Robert J. Troell, M.D., F.A.C.S.
(New Port Beach, California)

Address: 2801 East Coast Hwy
Suite E
Corona del Mar, New Port Beach, CA 92625.
Phone: (949) 220-0532

Driving Directions Contact Us
FPS ACOS AOHNS ASOLP AOHNS

BEFORE AND AFTER PHOTOS

Before & After

FACIAL

  • Chin & Cheek Enhancements & Implants
  • Ear Reshaping
  • Eye Cosmetic Surgery (Blepharoplasty)
  • Face Lift & Neck Rejuvenation
  • View all Facial

BODY

  • Abdominoplasty
  • Natural Breast Augmentation
  • Body Fat Grafting
  • Brazilian "Butt Lifts"
  • View all Body

SKIN

  • Body Scrubs & Wraps
  • BOTOX®
  • Chemical Peels
  • Dermal Fillers
  • View all Skin

ANTI-AGING

  • Biodentical Hormone Replacement
  • Comprehensive Anti-Aging Program
  • View all Anti-aging

© 2021 Dr. Troell - Beauty by Design
All Rights Reserved
¿Habla español?: DrTroell.com/es

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Las Vegas, NV

(702) 242-6488

Corona del Mar, New Port Beach, CA

(949) 220-0532
Legal/ Disclaimer | Privacy Policy | Procedures | Gallery | Testimonials | Blog | Financing | Contact Us | Sitemap | Patient Portal

Disclaimer: Beauty by Design does not promise results, as they may vary for both non-surgical and surgical procedures. This includes experimental procedures, like Anti-aging Therapy. All information on this site is intended for general purposes and is in no way a substitute for professional medical advice. Before and after photos on this website are Beauty by Design's actual patients, and all patients have given consent for use of these photos.

Dr. Robert Troell is a multi-board Certified Cosmetic Surgeon with a DEA number, and is permitted to dispense narcotics and pharmaceutical drugs. BOTOX® and Juvéderm® are registered trademarks of Allergan. Dysport®, Restylane®, and Perlane® are registered trademarks of Galderma.

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Recognition - Award from U.S. Senate
Recognition - Award from U.S. Senate