Forms

Patient Cares Services Forms

All required Forms must be completed prior to starting any Medical and/or Cosmetic/Aesthetic Dermatology services to ensure proper patient safety, diagnosis, therapy, treatment and care while also ensuring accurate streamline billing. as well

All patients must disclose medical history, current medications, and/or treatments for any illnesses and/or injuries, if your planning or trying to get to get pregnant, are pregnant or recently had a baby, all known allergies, including drug and food allergies history as well. 

Our treatments may use products that contain natural food or nut based ingredients, organic plant based ingredients, and cosmetically produced ingredients, and we want to ensure our patients safety is kept well guarded while we provided any of our quality medical and/or cosmetic dermatology serivces

Completing all necessary forms ensures we can safely and efficiently Provide you with the

Best Medical Health or Rejuvenation Aesthetic Services 

Patient Forms

Please choose the appropriate form listed below and complete all requested information and submitted prior to date of scheduled appt

 

Payment Information

Please choose the appropriate form listed below and complete all requested information prior to date of scheduled appt

 

  • Cosmetic / Aesthetic Dermatology Services forms of payment

    • Cash 

    • Care Credit 

    • Debit/Credit Card 

 

Please note:

  • Insurance as payments is NOT accepted services

 

We accept Visa, MasterCard, American Express Credit Card, Debit Card and/or Care Credit

No Checks

Other Forms

​Please choose the appropriate form listed below and complete all requested information prior to date of scheduled appt

 

                    www.ConciergeHRS.com

© 2018 by ConciergeHRS, LLC.  

Tel: 561-292-0036

Our Office is centrally located in beautiful Boca Raton, FL

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