Welcome to the office of Dr. Travis Shaw, MD. We specialize in Facial
Plastic and Reconstructive Surgery and Ear Nose Throat.
When I decided to start my own practice, I wanted to make visit to see
me a unique experience, unlike any other doctor’s appointment you
may have had in the past. I wanted to care for people in a different
way. I wanted to use what I learned from my mentor and best friendmy father. Dad was a physician who truly built a relationship with
his patients.
I believe that the most important part of the doctor patient interaction
is the relationship between you, your family, and your doctor. To that
end, I will spend time to learn not only why you came to the office,
but learn about you personally. I will do my best to explain things to
you on a conversational level- not from the point of view of the doctor
telling the patient his or her diagnosis and the surgery he will be
performing.
My philosophy in treating people’s appearance is to bring out the
inner you with the most natural results possible with the least
amount of downtime or discomfort. I will never recommend surgery
when an equal result can be obtained via a less invasive option.
You will never feel rushed and your appointments will be long
enough to cover the problems that you wish to address that day. I will
also provide you with my personal mobile phone so that you can
contact me anytime if the need arises.
I designed the office to feel warm and welcoming, not unlike your
favorite coffee shop or hangout. The space is open yet cozy, and is
designed to make your entire visit as pleasant as possible. There are
shared IPADs where you can check email, Facebook, or look at before
and after photos.
We are also committed to preserving the environment for our children.
Many of the building products and furniture are from sustainable
sources. We are committed to a near paperless office by using the latest
in technology and electronic medical records, recycling, eco friendly
restroom products and beverage service. I donate my unused medical
supplies to relief and missions organizations.
You will be personally greeted by our Concierge Laura Beth, who will
serve as your personal guide for your entire visit and will assist you
in making certain that all of your needs have been met.
I hope to welcome you to my new practice and consider it an honor
you have chosen me as your physician.
Travis Shaw, MD
Patient Information
Full Name: ___________________________DOB _________ Sex: M / F
Address: _______________________________________________ City:______________
State: ______ Zip:_________
Phone Numbers: (H) _______________________(Mobile): _______________________
(W)________________________ (Email): ______________________________
Preferred Method Of Contact: (H): (W): (Mobile): (Text): (Email):
SSN ___________________________ MARITAL STATUS: (S): (M): (D): (W):
Primary Care Physician ______________________________
Pharmacy ___________________________ Location______________________________
Phone_______________________________ Fax__________________________________
Emergency Contact:
Name: _________________________________________ Relationship________________
Phone:__________________________ Address: __________________________________
City:__________________________ State: ________ Zip: __________
How did you hear about us?
_____________________________________________________________________
___________________________________________________________________.
What brings you to see us today?
____________________________________________________________________________________________
____________________________________________________________________________________________
______________________________________.
If you are hoping to make a change in your appearance, what do you
hope this change would do for you? (For example, make me feel more
confident, make me look more well rested, get me ready for my class
reunion etc.)
____________________________________________________________________________________________
____________________________________________________________________________________________
_____________________________________.
Do you have now or a history of the following? (please check all that
apply):
__ Alcohol/Drugs Anemia
__ Hypertension
__ Asthma
__ Bleeding Disorder or bruise easily
__ Nasal Allergies
__ Nose Bleeds
__ Post-Nasal Drainage
__ Sinus Infections
__ Depression Anxiety
__ Stroke
__ Scarring
__ Ulcers
__ Diabetes
__ Difficulty breathing through nose
__Earaches
__ Headaches
__ Heart trouble
Please list current medications:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________.
Please list ALL known drug allergies:
____________________________________________________________________________________________
________________________________________________________.
Please list previous surgeries or major illnesses with dates
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________.
Check any cosmetic treatment you might like to discuss with Dr.
Shaw:
Procedures
Injectables
__ Rhinoplasty
__ Botox
__ Facelift
__ Restylane
__ Neck lift
__ Juvederm
__ Blepharoplasty (eyelid lift)
__ Radiesse
__ Brow lift
__ Cheek Augmentation
__ Chin Augmentation
__ Otoplasty (ears)
What concerns do you have regarding your skin?(check all that
apply)
__Tattoo Removal
__ Brown Spots
__ Wrinkles
__ Acne Scarring
__ Photo-damage
__ Sagging Skin
__ Large Pores
__ Rosacea
What type of skin treatments interest you?(check all that apply)
__ Facial Peels
__ Microdermabrasion
__ Skin Tightening
__ Laser Resurfacing
__ Wrinkle Reduction
Insurance Information
Primary Insurance:____________________________ Policy ID:___________________________
Group #:________________ Group Name______________________
Policy Holder:_________________________ DOB__________ Sex: M / F
SSN______________
I hereby authorize the release of medical information to insurance carriers
and/or other physicians, and also for benefits to be paid directly Travis
Shaw, MD. In the care of a minor, I authorize the filing of insurance claims.
I understand that I am responsible for all charges (including non-covered
charges) arising for the treatment of the named patient. Should this account
become delinquent, I agree to pay all collection and court costs, including
attorney’s fees.
Signature ____________________________________________
Date __________________