New Patient Forms
Upon scheduling, you will receive an email link to complete forms online. If you are unable to do so, please let us know and we can provide paper copies.
Patients must complete all forms and agree to the cancellation policy prior to your scheduled appointment.
New Acugems Facial Rejuve™ Forms
Upon scheduling, you will receive an email link to complete forms online. If you are unable to do so, please let us know and we can provide paper copies.
Patients must complete all forms and agree to the cancellation policy prior to your scheduled appointment.
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