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Patient Forms

If you have an virtual appointment, click on the correct image below to enter the “waiting room” at your appointment time.

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Dr. Janssen

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Dr. Doubek

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Jay

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At Fox Valley Plastic Surgery, we want to make sure that we have all the necessary information about you before we begin any treatments.

In order to hasten the patient intake process for patients from Appleton, Green Bay, Oshkosh and the Fox Cities, we encourage you to download and complete the necessary forms in advance of your appointment.  Click on the form, and a pdf version of the paperwork will appear.  If you need Adobe Reader, please click here.  Please print the forms on your printer.

After you complete the forms, you can fax the forms back to us at 414-386-4625, mail them to us, or bring them to your appointment.

Check In Documents

• Breast Implant Illness Consultation Questionnaire
• Breast Implant Illness Post Explantation Questionnaire
• Fox Valley Plastic Surgery Forms
• Laser Institute of Wisconsin™ Forms
• Lifestyle Therapies Forms – Female
• Lifestyle Therapies Forms – Male
• Medispa Forms
• Vein Forms

• Breast Reconstruction Booklet
• Allergan Breast Implants – Patient Education Silicone Natrelle
• Mentor Breast Implants – Patient Education Mem Shape AUGMENTATION
• Mentor Breast Implants – Patient Education Mem Shape RECONSTRUCTION
• Mentor Breast Implants – Patient Education Mem Gel Extra AUGMENTATION
• Mentor Breast Implants – Patient Education Mem Gel Extra RECONSTRUCTION
• Mentor Breast Implants – Patient Education Saline Implants
• Sientra Breast Implants – Patient Education AUGMENTATION
• Sientra Breast Implants – Patient Education RECONSTRUCTION
• Consent for Nicotine Testing (required for some surgeries)
• Notice of Privacy Practices (for all patients)
• Patient Rights and Responsibilities

• Medispa Brochure
• Halo™ Laser Brochure
• Halo™ Laser Post Procedure
• Restylane® Patient Brochure
• Restylane® Kysse Fact Sheet
• Restylane® Defyne Patient Brochure
• Restylane® L Patient Brochure
• Restylane® Lyft Patient Brochure
• Restylane® Refyne Patient Brochure
• Restylane® Silk Patient Brochure
• Sculptra® Aesthetic Patient Brochure

Emsculpt/Emsella Clinicial Studies

• Emsculpt abs waist circumference reduction
• Emsculpt abs tomography fat and muscle effect
• Emsculpt abs MRI fat and muscle effect
• Emsculpt buttocks effect
• Emsculpt buttocks lifting
• Emsella clinical study
• Emsella mechanism in action

Stratpharma Information Sheet

• Strataderm® Information Sheet

Vein Pre and Post Op Information Sheets

• Echo Sclerotherapy
• Endovenous Laser Ablation
• High Thigh Ligation
• Incision and Drainage
• Radiofrequency Ablation
• Sclerotherapy
• VenaSeal