The Center for Facial Plastic Surgery
Gary S. Churchill M.D., F.A.C.S.
515 Old Northwest Highway
Barrington, IL 60010
0 847-304-1000
F 847-304-1182
Drchurchill.com

Welcome to: The Center for Facial Plastic Surgery! The Primary objective of our office is to provide excellent quality of care in the area of facial plastic surgery, aesthetic skin care and our injection and laser specialties. We want to make sure that all of our patients are as comfortable as possible with the staff so that all of their questions can be addressed.

Surgical consultations with Dr. Churchill are virtual and there is a one-time fee of $95.00. You have probably waited a long time for your consultations so please write down all of your questions. I also encourage you to view the video section on our website where Dr. Churchill explains his procedures in great detail. After the consultation I will email you the fees for the proposed procedures and the option to schedule.

Enclosed are new patient forms and photo instructions for your completion.

We look very forward to meeting you!
Sincerely,

daisy@drchurchill.com
Daisy McConnell, Office Manager

 

Your Rights and Responsibilities as a patient of
The Center for Facial Plastic Surgery

Patient's Rights:
  • You have the right to be treated with respect, consideration and dignity.
  • You have the right to total privacy regarding your care and confidential records. No records to be release unless a patient directs us to do so.
  • You have the right to be provided to the degree known, complete information about your treatment.
  • You have the right to exchange physicians if other qualified physicians are available.
  • You have the right to refuse to participate in experimental research.
  • Your photographs are used for identification purposes only, unless directed by the patient.
  • Survey questionnaires will be made available to you.
  • You have the convenience of calling our office 24 hours a day and if necessary, your doctor Chunch can be paged.
  • You have the right to express any and all grievances to our office manager. daisy@drchurchill.com, in witing: 515 Old Northwest Huy, Barrington, IL 60010, or contact our facility's accreditor: AAAASF 888-545-5222
Patient's Responsibilites:
  • When making an appointment, it is the patient's responsibility to tell the receptionist the nature of the visit so that the proper amount of time can be allotted.
  • The patient is responsible for providing the staff with the proper contact information.
  • The patient is responsible for reading and signing all of the required forms provided to them.
  • The patient must also be responsible to follow pre and post-operative instructions and to provide our office with any surgery required test results in a timely matter.
  • It is the patient's responsibility to call the office if there are any symptoms experienced which are not described as normal following surgery.
  • It is important that the patient notify the staff in advance to change an appointment.
  • The patient must accept financial responsibility for all charges incurred and must see to it that all surgical procedures are paid in full in advance.
  • Your opinion is very important to all of us. If the patient has a concern, it is the patient's responsibility to bring it to the attention of our staff who will make every effort to resolve the issue.

Thank you in advance for your understanding of the measures above.
They are designed to keep the quality of practice at its best!

HIPAA Compliance Requirements

The Center for Facial Plastic Surgery is required by law to maintain the privacy of our patients and to provide each individual with this notice with respect to protected health information. If you have any concerns or objections to this form, please ask a staff member for further details about HIPAA compliance requirements.

 

Welcome to the Center for Facial Plastic Surgery and
The Center for Facial Aesthetic Skincare

New Patient Registration
Responsible Party Information (If Patient is a minor)
Medical Information
Please Check any/all of the following that apply to you

The information that you have provided us is essential in our comprehensive evaluation of your case. Please feel free to write down any questions that you may have so that we may discuss them in detail during your consultation.

Thank you for choosing The Center for Facial Plastic Surgery!




Financial Policy for: The Center for Facial Plastic Surgery

Dear Patient,

Thank you for choosing The Center for Facial Plastic Surgery. We would like to explain our financial policy in advance in order to avoid any misunderstanding. There is a one-time fee of $95.00 for a surgical consultation and it does not go toward your procedure.

We require a non-refundable deposit in order to schedule a surgery under twilight sedation and the balance in due in full 2weeks prior to surgery. fI surgery is cancelled within the 2 weeks the total is non-refundable. Al other procedures require payment in full at the time of service.

Dr. Churchill has opted out of Medicare, therefore there is no coverage if you are a Medicare recipient. Dr. Churchill is a non- participating provider for all other insurance plans, therefore any covered procedures would only qualify for minimal reimbursement to the patient if any at all.

Please be sure that a parent or guardian accompanies patients under the age of 18, otherwise we reserve the right to refuse treatment.

We appreciate your cooperation in this matter. These policies were adopted in order to provide all patients with the best possible professional care. We feel that clear communication in advance helps to contribute to the best relationship with our patents.




Home Photo Instructions

Due to the current pandemic we have taken measures to reduce the flow of people coming and going from our office. In keeping with that, we have adopted telemedicine to the extent it is possible in our practice. Since photographs are unable to be taken in the office, we developed these guidelines for you to take acceptable photographs at home for use during your telemedicine consultation.

  • Photos should be taken in front of a blank wall with good natural lighting.
  • Please stand about one foot in front of the wall and hold your head in a neutral position, not chin down or chin up.
  • Have another person use a cell phone and set the zoom to 5x. (On most iPhones, that will be zoomed in as far as it will go. You should see the 5x at the bottom of the screen. On an android phone you may be able to zoom in further so only zoom to 5x.)
  • The phone should be held vertically, and a series of photos should be taken at each position as follows.
  • Pretend you are standing on a clock. Now point your toes to 12 o'clock. This is the straight on position. Keeping your head facing in the direction of your body, shift your feet so they are pointing toward the point between 1 and 2 o'clock. This is the left ¾ position. Again, without turning your neck, turn your body so your feet are pointing at the 3 o'clock point. This is the left profile position. Turn the opposite direction pointing your feet toward between 10 and 11 o'clock. This is the right 3/4 position. Lastly, turn your feet to 9 o'clock. This is the right profile position.
  • Take photos at each position. The photos should be framed so your entire head is visible and centered. (Again, we want your head in a neutral position with your chin neither up nor down.)
  • Please email your photos to daisy@drchurchill.com

Thank you for taking the time to doing this prior to your virtual consultation. Having your photos to work with during your consultation will be a great help.