Patient Forms

You may print and fax the following patient forms to Fayetteville Plastic Surgery at 910-222-3068. If you have any questions please contact us at 910-323-3757.

FPS New Client Intake
Reservation & Cancellation Policy (effective 8-1-2017)
Dr. Edward Dickerson Referral Form
Medical Intake Form
Medicare_Medicaid Supplemental Form
HCG Weight Loss Intake & Consent
Media Release Consent
Fillers Consent
Botox/Xeomin Consent
Laser Hair Removal Consent

NOTE:  PDF files require Adobe Acrobat Reader to view. If you do not have Acrobat Reader, you can download a free copy here.

Dr. Edward Dickerson, Medical Director of Fayetteville Plastic Surgery Specialists and Cape Fear Aesthetics Med Spa offers surgical, non-surgical, and laser cosmetic and anti-aging procedures for the face and body at the only AAAHC Certified Office Cosmetic Surgery Center in Cumberland County. The full-service Med Spa provides advanced skin care and body work, as well as laser hair removal and laser tattoo removal.