Patient Forms

Please print the appropriate form listed below and return the completed form to the office for your appointment.

• Allure Insurance/Medically Necessary Patient Forms

• Allure Cosmetic/Non-insurance Patient Forms

• Allure Cosmetic Aesthetic, Facial Patient Forms

• Two Rivers Patient Demographics Form

• Two Rivers Authorization Statements for Insurance Program Form

• Two Rivers HIPPA Privacy Rule (PHI) Form

• Two Rivers HIPPA Notice of Privacy Practices Form

• Two Rivers Patient Rights/Responsibilities Form

• Two Rivers Healthcare Information Disclosure Form

• Two Rivers Facility Consent Form

• Two Rivers Advance Directives – Living Will Form

• Two Rivers COVID-19 Risk Informed Consent Form

• Two Rivers Financial Disclosure Statement

Instructional Videos can also be found on the Allure Patient Portal through the Symplast application.