Patient Forms

The links below contain downloadable electronic patient registration and medical history forms. Both can be filled out and printed directly from your computer, or hand-completed and handed back to our staff at the time of your appointment. These forms are provided to decrease the time you spend waiting for your consultation.

Patient Registration

Patient Medical History

To view these forms, a PDF Adobe Acrobat Reader is required

Pre/Post Operative Instructions

Below are links to printable versions of these Pre and Post Operative Instructions so you can print share with family what to expect before and after your surgery.

Pre Operative Instructions

Clear Liquid Diet

Post Operative Instructions

To view these forms, a PDF Adobe Acrobat Reader is required


Our office is committed to delivering the highest quality healthcare. Most surgical services are covered under traditional healthcare insurance plans.

We accept most traditional PPO plans, including but not limited to Blue Cross/Blue Shield, United Healthcare, Cigna, Aetna, Golden Rule, Beech Street, AvMed, Medicare and many others. Please call us for a complete listing of covered plans.

Co-pays are due at the time of your visit and can be paid by credit card, debit card, check or cash. We accept American Express, Visa, and Mastercard.

Balances due after your insurance company has paid their percentage of the allowed reimbursement is forwarded to you in your patient statement.

Note: Some cosmetic procedures may not be covered under traditional health care plans, and we make every effort to convey this information to our patients prior to any surgery scheduling.

No Insurance Surgery

There are times when patients without insurance need an operation. For these patients, Dr. Koller offers special discounts and payment options to help patients get the surgery they need with the same quality and convenience provided to patients who have insurance coverage. Most patients who lack insurance coverage or who have high out-of-pocket deductibles can be seen and cared for as any other patient.

Surgery is always performed in an approved hospital operating room or outpatient surgery center. Usually, all pre- and post-operative care is included in the cost of an operation. There are no hidden fees or unnecessary expenses. All costs are explained up front and all questions are thoughtfully answered. There is no reason to put off that necessary operation any longer. Quality surgical care by a Board certified surgeon is now just a phone call away. Call us today to find out if you qualify for no-insurance surgery.