Early Patient Registration

Please contact our office, set an appointment, and bring the completed form with you to the appointment.

If you would be so kind as to fill out  the following form , as completely as possible,  we feel you will experience an increase in the quality of service and speed in the registration process for patients during their initial appointment.  All your information will be kept completely confidential and we will never give your information to another company.  If a question does not apply to you, please write “na” (not applicable) or “none” in those fields.  Every field is required for us to accurately process your registration form and to insure you did not miss any questions accidentally.

Thank you, and we look forward to meeting you and taking care of you at your first appointment.

Thank you for contacting the plastic surgery practice of Dr. John K. Long in Houston. We look forward to seeing you for your consultation.

John K. Long, M.D., F.A.C.S.
1200 Binz St., Suite 1275
Houston, Texas 77004
Phone: (713) 522-5664
Fax: (713) 522-9618