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910-338-5918

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Patient Forms

You may print and fax the following patient forms for Fayetteville Plastic Surgery & Cape Fear Aesthetics to 910-222-3068.

	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.

PATIENT TESTIMONIALS

“The staff is amazing. I just love this place.” -Robin Barnes

PATIENT TESTIMONIALS

“It’s like night and day from where I was before. I am no longer on my way to becoming a diabetic.” -James Pilgrim

PATIENT TESTIMONIALS

“I love Dr. Dickerson and his staff. They are so comforting, warm, welcoming… they make you feel at home.” -Tamu Brown

PATIENT TESTIMONIALS

“As soon as I came in I automatically felt at ease. Everyone is warm and courteous.” – Dinah Goodman

BEFORE & AFTER

GALLERY

LOCATION

VISIT US AT

2053 Valleygate Drive #102
Fayetteville, NC 28304

910-338-5918

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