Patient Registration Form


Welcome to the Patient Forms section of our website! In order to expedite the administrative process of your first visit, you may choose to fill out the required paperwork online. The below form is a secure, HIPAA-complaint form that will be received by our office administrator.


If you would feel more comfortable filling in this paperwork in-office, please feel free to do so by arriving 20 minutes before your first appointment at our office. You may also choose to fill out this form offline by downloading it in PDF form by clicking here. Once completed please send to Dr Jacobsen’s staff by email info@drjsoffice.com or fax at 602.279.1701.

Dr J and his staff look forward to understanding the details of your unique case, desires and aspirations, and to providing you with realistic, safe and attainable results that leave you looking beautiful, and truly feeling like yourself. Take the first step toward your healing or rejuvenating procedure with Dr J by filling out our contact form to request a consultation, or to inquire about any of the services we offer. We look forward to treating you!


4.9 Average Rating  |  Click to view over 370 reviews



4.8 Average Rating  |  Click to view over 170 reviews



4.7 Average Rating  |  Click to view over 120 reviews
  • review rating 5  Great experience with Dr Jacobsen. I had a tummy tuck, breast lift with implant exchange and I am very happy with the results. Dr. J came to the hospital the night after I had the surgery to check on me. Very impressed. Dr J did a wonderful job and I will highly recommend him. "High Class" Doctor and office as well. Thank you. (01/10/19)

    thumb Ellie Proteasa
    1/11/2019
  • review rating 5  I honestly cannot say enough about the entire experience. From the girls at the front to Dr. J, nothing was short of first class excellence met with an one of a kind feeling of being amongst people who really care. Whether its the little things of being offered water for every visit or Dr. J himself, you just get an incredible unrivaled experience here. Dr. J is extremely nice and genuine to say the least, and his work shows! I had a nasty raised scar from a dog bite and was really nervous to have that taken out, but the whole experience was virtually painless and smooth. Not to mention what Dr. J did was just flat out impressive. I can barely even tell there was anything there to begin with..so so thankful.

    thumb D OD
    2/17/2019
  • review rating 5  My experience with Dr Jacobsen, MD has been a stunningly positive experience. Is he a highly skilled surgeon? Yes, without a doubt and I would not hesitate to seek his help with any problem whatsoever. He is an excellent communicator and answers any and all questions and concerns so that I knew what was going to happen and what to look forward to. His staff is excellent as well. Dr Jacobsen has put together a highly professional team across the board. Bob N. 2/28/18

    thumb Ive Nuffet
    3/01/2018
  • review rating 5  I'm having a hard time with this because, I can't say enough good things about this office! Dr. Jacobsen is an amazing surgeon. He is always available, for any questions or concern. His staff go way beyond any other office I have seen. They are more than helpful with insurance, appointments, or any issue or questions. The office is both beautiful, and comfy. Like I said can't say enough.

    thumb J Basom
    1/25/2018
  • review rating 5  My dad is the best Dad. Do not try to tell me otherwise please and thank you.

    thumb Oliver Jacobsen
    2/18/2019
  • review rating 5  I couldn't be happier with my procedure. Dr. J has the most kind and relaxing manner and he is the ultimate professional. I had a fatty tumor on my forehead that he removed, as well as breast reconstruction. The breast reconstruction was overdue as I had breast cancer with multiple lumpectomies, biopsies and radiation. It left the tissue hard and my old implant like a rock. He was able to correct all of the problems and I'm much happier with my appearance. Although you may find it odd at first that you can't get anyone by phone their response time is amazing. I emailed the office on a Sunday afternoon that I had a problem and within ten minutes (no exaggeration) I had a text back that a prescription had been called in to my pharmacy. I've had procedures with other doctors around the Valley and never had an experience more pleasant, nor one which I was happier with the results.

    thumb Leslie Keller
    10/16/2017
  • review rating 5  Incredible does not begin to describe Dr. J and his amazing staff! From my first consultations to any questions I had post op, I was treated like I was the only patient. Dr. J is a true professional who cares about his patients. Without hesitation, I highly recommend Dr. J!!

    thumb Kara Sehr
    3/10/2019
  • review rating 5  My experience with Dr Jacobsen, MD has been a unbelievable first time experience for my procedure. He is a extremely skilled surgeon that that I would highly recommend. He is professional, compassionate, knowledgeable and has excellent bedside manners. Do not hesitate to set up a free consultation, your will never regret it. Jim K. 4/15/18

    thumb Jim Kleeman
    4/17/2018
  • review rating 5  I had skin cancer removed from my forehead for the first time and my dermatologist's office scheduled an appointment with Dr. Jacobsen on my behalf. Not only was the staff accommodating but they actually got another patient to reschedule so that they could fit me in to close up the (rather large!) wound. I still had no idea what was going on, what everything was going to look like, how much it was going to cost, etc and I was under a considerable amount of stress. Every staff member I interacted with put me more and more at ease; they're more worried about you as a person than they are about you as a payment. Dr. Jacobsen is very kind and so concerned about the wellbeing and comfort of his patients. I was in very good hands. I am now going through round two and I am back in his hands -- and couldn't feel more secure. The pictures shared are from my first procedure -- about 2 weeks apart. The scar has disappeared even more and is nearly unnoticeable even without a light layer of makeup (as in the after photo)

    thumb Kristen Costanza
    6/15/2018
  • review rating 5  He is the best doctor I am so so happy with my tummy tuck thank you DR William m .Jacobson

    thumb Nehmah Salem
    2/12/2019

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