Melbourne, FL: (321) 951-2639
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Melbourne, FL: (321) 951-2369

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Home | Patient Resources | Patient Forms

Patient Forms

On this page you can download the forms you'll need to complete prior to your consultation visit with us. Completing these forms ahead of time saves you time in our waiting room and helps us expedite your consultation. If you have any questions while completing the forms, don't hesitate to call us at (321) 951-2639. You will need a version of the free program Adobe Reader to view or print the following files.

Patient Forms

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  • HIPPA Patient Privacy Consent Form
Patient Resources
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Copyright © 2010 - 2012 Michael Diaz, M.D.
Riverfront Building
304 South Harbor City Blvd., Suite 101
Melbourne, Florida 32901
Phone: 321-951-2639

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Dr. Michael Diaz is a board-certified plastic surgeon who specializes in plastic and reconstructive surgery of the breasts and body. He performs a variety of advanced procedures including liposuction, and tummy tucks, and breast augmentation in Orlando. He also offers medical spa treatments like injectable fillers and BOTOX® Cosmetic. Patients visit Dr. Diaz at his office in Melbourne from cities all around Central Florida including Orlando, Merritt Island, Viera, Cocoa Beach, Vero Beach, Sebastian, Suntree, Satellite Beach, Indian Harbour Beach, and Melbourne Beach.

THE PATIENT AND ANY OTHER PERSON RESPONSIBLE FOR PAYMENT HAS A RIGHT TO REFUSE TO PAY, CANCEL PAYMENT, OR BE REIMBURSED FOR PAYMENT FOR ANY OTHER SERVICE, EXAMINATION, OR TREATMENT THAT IS PERFORMED AS A RESULT OF AND WITHIN 72 HOURS OF RESPONDING TO THE ADVERTISEMENT FOR THE FREE, DISCOUNTED FEE, OR REDUCED FEE SERVICE, EXAMINATION, OR TREATMENT.