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500 Superior Ave #335, Newport Beach, 92663, CA BILLING PATHOLOGY
To Make an Appointment Text or Call: 949.706.1469

Established Patient Paperwork

    PHARMACY: All prescriptions will be sent to ABC specialty pharmacy. ABC pharmacy takes care of any prior authorizations needed and will mail medications to your home.
    What brings you into our office today?:
    Please confirm any newly prescribed OR over the counter medications since your last visit:
    Please confirm any new allergies since your last visit?:

    Please confirm your smoking status:
    If you’re a smoker, would you like help quitting?:

    Review of Systems: Are you currently experiencing any of the following?

    Please confirm any new alerts since your last visit (Please check all that apply):

    What would you like to learn more about?
    Other - Please Specify:
    What is your skin care regimen?:
    Refund Policy: Products purchased are final sale. No refunds are made for individual services, packages and pre-paid treatments once they are purchased. If for some reason you are not able to use an un-rendered, pre-paid service, credit for the pro-rated share of unused treatments at the discounted package price may be extended, and this may be used to purchase other treatments or products offered by Pure Dermatology.



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