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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.

Health History      
We will have a few other simple forms to be completed at the office prior to your appointment. 

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 Health History

Medical Claims Forms

We are happy to provide insurance billing for you (Seattle Location ONLY), 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. 


1845 Highway 126
Florence, OR 97439
Call (541) 991-3917