Medical Forms

Here at Coastal Surgeons we want your experience with us to be as pleasant as possible. Having your paperwork prepared before you arrive will help speed up your check in process.

New Patient Information and Financial Policy

Instructions: Please fill out new patient information completely. Also, read and sign the financial policy portion. Bring form along with your insurance card to your first visit.

Patient Registration Click Here

Health Insurance Portability and Accountability Act

Instructions: Please read and sign Notice of Privacy Practices. Bring signed form with you to your first visit.

HIPAA Notification Click Here
Health History Questionnaires

Instructions: Please fill out as completely as possible. Bring form with you to your first visit.

Health History Questionnaire Click Here
Dr. Toosie Health History Questionnaire Click Here
Breast Questionnaire

Instructions: Please fill out the top portion of the form prior to your visit. Bring form with you to your visit.

Breast Referral Questionnaire Click Here
List of Insurance Plans Accepted by Coastal Surgeons

Coastal Surgeons accepts most government and commercial health insurance plans. In all cases verify with your insurance company that Coastal Surgeons is a contracted provider. We also accept cash paying patients.

Patient Financial Agreement Form

Instructions: Please read and sign all sections of this form. Bring it with you on the day of your appointment.

Patient Financial Agreement Form Click Here
Medication List

nstructions: Please read and sign all sections of this form. Bring it with you on the day of your appointment.

Medication List Form Click Here