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-compliant 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  I would recommend dr. William Jacobsen to anyone who is interested in doing any kind of procedure. I got a chest augmentation and he did an amazing job! I am very happy and he did exactly the shape and size I was wanted. Go to his website and you will not be disappointed !

    thumb Mirela Eastridge
    2/20/2019
  • review rating 5  I went to Dr. Jacobsen a few weeks ago for surgery on a keloid scar I had on my chest that was ugly and slightly painful. He removed that awful scar and it looks great now, it’s only a few weeks but I can already see a huge difference in the healing process. The procedure was also painless and he was great!

    thumb Stephanie Collins
    10/31/2019
  • review rating 5  Dr J is the best! I have an ongoing issue with a medical implant that he has cleared up several times. Every time I contact him he is right there. This last time he actually met me on a Sunday to help me. I highly recommend Dr J. His bedside manner makes you feel that no matter what everything will be okay.

    thumb Donna Brockway
    7/14/2019
  • review rating 5  Dr Jacobsen performed surgery on the back of my leg to remove melanoma, I also had a sentinel lymph node biopsy at the same time. Dr J is professional, knowledgeable and very dedicated to patient care. I had to have the lymph node incision drained several times and he got me in quickly and also worked around my hectic schedule. He even came in while he was on vacation! He was always so reassuring and very kind. Dr J goes above and beyond! His office staff is very responsive and they are so pleasant to work with. I am grateful to have been referred to Dr J and his office😌

    thumb Pam Kline
    7/22/2019
  • review rating 5  I've had four visits with Dr. Jacobsen over the past 2.5 years, the first after the removal of 1/3 of my bottom lip from skin cancer, and the last for a biopsy of possible skin cancer on my nose. Each time, he has treated me with kindness and respect, and also had a level of confidence that made me feel relaxed with whatever he thought best for the particular problem. Thus far, the results have proven him correct. He has quickly become my go-to for any problem or condition that may create a cosmetic "issue". His office and staff make you feel welcomed and comfortable, and he promptly and generously responds to questions or concerns by email. One visit and you'll find these things out yourself.

    thumb Jay Phillips
    4/18/2018
  • review rating 5  Dr. Jacobsen is a great surgeon. He performed surgery on my melanoma 4 weeks ago and has been very good about following up to help me feel comfortable. He often returns my calls to his office personally and makes time to see me when I am concerned. His office is lovely and well-run. The staff is efficient and caring. My calls are returned promptly. I feel fortunate to have Dr. Jacobsen for a doctor.

    thumb Karen Atkins
    7/12/2019
  • 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  Dr J is a kind, compassionate, extremely gifted surgeon. I’ve now had two procedures preformed by him and both he explained and executed beautifully. He is always there to answer questions before and after surgery. You will most likely wait about a hour longer then your expected appointment time but he is definitely worth the wait.

    thumb Jennifer Arena
    5/14/2019
  • review rating 5  Dr. J and his entire staff are the BEST! He was personally so responsive to a weekend email about my son's accident that resulted in a cut on his chin. Dr. J and his staff made sure to fit my son in to see Dr. J immediately. We have confidence that my son's wound will heal well after receiving care from Dr. J. Thank you Dr. J!

    thumb Marsha Dobric
    4/06/2019
  • 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

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