Adult, Pediatric & Cosmetic Dermatology, Laser & Skin Surgery | Tucson, AZ | Botox
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Please allow 24 – 72 hours for a response to your email. If you have medical issues or more urgent concerns, please contact us at (520) 795-7729.

For medical emergencies, please call 911.

Thank you.

Patient Registration Forms

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New Patient Forms & Information

  • Please print, fill out, and bring the New Patient Forms with you to your first visit to our office.
  • These forms can be downloaded from the links below.
  • If you are an existing patient, you may also use these forms to update your information. 
  • Please arrive 15 - 20 minutes early for your paperwork to be processed and to keep your appointment running on time.
  • Please bring your Photo ID and Insurance Card.
    •  

     

    Registration
    Medical History
    HIPAA / Advance Directive
    Payment Policy
    Credit Card On File Agreement

    If the patient is under 18 years of age, please download and complete this form:


    Consent for Treatment of Minor

     



    The following insurances are those we are currently contracted with. If there is any concern about coverage, always check with your insurance to be sure we are contracted.  

    Aetna Health Insurance

    Arizona Foundation for Medical Care

    Assurant Health / John Alden
      
    Beech Street

    BlueCross BlueShield
        
    CIGNA HealthCare
        
    Community Care Network

    Coventry
        First Health / The First Health Network

    Great West Healthcare
        
    Health Net  

    HMN (Health Management Network)
       RAN/AMN 

    Humana

    Medicare
        Railroad Medicare
        
    Multiplan
        PHCS
      
    Sterling Option I

    Tricare West (standard only)
        Tricare for Life (secondary only)
        
    United Health Care
        Evercare
        PacificCare Fee for Service 
        AARP Medicare
        Principal Health Insurance

    University Physicians Health Care Group                                                                     

    We file claims to insurance companies providing coverage secondary to Medicare or Tricare, whether contracted or non-contracted. Those claims to non-contracted carriers are crossed over electronically from the primary payer or submitted once by paper as a courtesy to our patients. We are not able to refile or appeal claims to non-contracted carriers. If a non-contracted insurance carrier fails to pay within 30 days of our filing, the balance becomes the patient’s responsibility and will be billed accordingly. 


    Questions regarding coverage should be directed to your insurance carrier’s Membership Services or your employer’s Human Resources Department. Be aware that many insurance carriers have websites with listings of contracted providers.