Beauty by Design

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.

Step 1 of 3

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  • Cosmetic Patient Registration

  • Please let us know how you were referred to our practice (circle item):
  • Patient Information

  • Date Format: 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.
  • Date Format: MM slash DD slash YYYY

Beauty By Design – Las Vegas

7975 West Sahara Avenue Suite 104 & 103
Las Vegas, NV 89117
United States (US)
Phone: (702) 242-6488

Monday8:30 AM - 4:30PM
Tuesday8:30AM - 4:30PM
Wednesday8:30AM - 4:30PM
Thursday8:30AM - 4:30PM
Friday8:30AM - 4:30PM
Saturday8:30AM - 1:30PM
SundayClosed

Beauty By Design – Corona Del Mar

2801 East Coast Highway Suite E
Corona Del Mar, CA 92625
United States (US)
Phone: (949) 220-0532

Monday8:30 AM - 4:30PM
Tuesday8:30AM - 4:30PM
Wednesday8:30AM - 4:30PM
Thursday8:30AM - 4:30PM
Friday8:30AM - 4:30PM
Saturday8:30AM - 1:30PM
SundayClosed
Facial Plastic Surgery American College of Surgeons American academy of cosmetic surgery American society of liposuction surgery American academy of otolaryngology head and neck surgery

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