Registration Information

Tell Us Your Story and Vision

Your health is of utmost importance to Cosmetic Plastic Surgery of Illinois. Therefore, to ensure that we have all the needed information to properly care for you, we have several patient information forms for you to complete.

New Patient Registration Forms

Please remember that accuracy and honesty are extremely important when filling out any official paperwork, especially that related to your health. Download and fill out these forms before your appointment to save time!

Submitting Registration Forms

Although these forms are available online, they are not electronically submitted. Please print completed forms, sign and bring them with you to your appointment.

These forms have been saved in Adobe® Acrobat® for your convenience. They require Version 7.0 or above. A link has been provided below if you are in need of this software. We cannot guarantee the functionality of the software in the link below. We provide this link to you “as is”, and you agree to use it at your own risk.

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Please fill out the following fields. We’ll reach you as soon as possible. Thank you!


Cosmetic Plastic Surgery of Illinois
Proctor Professional Building

5401 N Knoxville Ave. Suite 416
Peoria, IL 61614


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