Patient Encounter Form

NOTICE TO CONSUMERS: Dr.Creasman is licensed to practice medicine by the medical board of California (800) 633-2322 / ( He is certified by the American Board of Plastic Surgery.

(*)=Required Field

Phone Numbers (###)###-####

Emergency Contact Person


By signing below, I hereby acknowledge that I have been offered a copy of the "Notice of Privacy Practices" and any amended notice at each appointment and further acknowledgement that a copy of the current notice is posted in the reception area.

I attest that the information provided above is accurate and true to the best of my knowledge. I understand that I am responsible to pay for services rendered including attorney's fees and cost of collection in the event of default. I further understand that if payment becomes thirty (30) days past due, delinquency charges at the lesser of the annual rate of 15%, or the maximum allowable rate, will be due on the delinquent amounts from the date the payment was due.

Type your full name in the box

Date (mm/dd/yyyy):
Secured by Paubox Encrypted Email - HITRUST CSF Certified