New Patient Forms
Please download and complete the following forms. If you are not able to download these forms, please arrive at least 10-15 minutes prior to your appointment time to do so.
New Acugems Facial Rejuve™ Forms
In addition to the above two forms (New Patient Packet, and Health History), please download and complete the following forms.
Medical Claims Forms
We are happy to provide insurance billing for you (Regency BCBS, and PIP claims ONLY), however in the case of claims denial the balance will become your responsibility. For other insurance carriers, you may pursue reimbursement by submitting a receipt along with the appropriate medical claims form to your insurance company. These forms can also be found on your insurance provider's website.
1845 Highway 126, Unit H
Florence, OR 97439
Call (541) 991-3917
Fax (541) 991-3918