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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 Patient Packet   
Health History          

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.

Facial Rejuve™ Intake
Facial Consent Form

Medical Claims Forms

I will be happy to provide insurance billing for you, however in the case of claims denial the balance will become your responsibility and 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. 


Ballard Clinic:
1551 NW 54th Street, Suite 204
Seattle, WA 98107
(206) 931-4500

Call or text (206) 931-4500


Fax (206) 557-4942