Cosmetic Surgery & Laser Center of El Paso Online Registration

Online Registration

 
Dr. Reynolds, Dr. Jabor and their Cosmetic Surgery & Laser Center of El Paso staff will be happy to answer any questions or address any concerns. To ensure that you are promptly seen or if you are unable to keep your appointment, please call us 24 hours in advance.

  • Fill out the form below to register online.
  • Information

    • Yes  No
    • Male Female
    • Single
      Married to:

      Other:

  • Employer

    • Yes  No
  • Emergency Contact

  • Primary Insurance

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  • Secondary Insurance

    • Yes  No
    • Yes  No
  • Referral Information

  • Questionnaire

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    •  No Yes
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  • Health Issues

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      Mo. Yr.
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I understand that office visit charges are payable on the day service is rendered. I authorize Dr. R. Dale Reynolds and/or Dr. Mark A. Jabor to bill my insurance company. Regardless of insurance coverage, I am responsible for all bills being paid in a timely manner. I understand that my contract is between Dr. R. Dale Reynolds, Dr. Mark A. Jabor and myself.

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