Get In Touch
Call: (541) 450-9792
Email: roguerevitalize@gmail.com
Business Hours
- Mon - Fri
- -
- Sat - Sun
- Appointment Only
After Hours Appointment Only
New Patient Forms
We're excited to welcome you as a new patient! To make your first visit seamless, we kindly request that you complete the necessary forms provided below. Please bring your completed forms with you to your appointment. We look forward to seeing you!
Required Forms for All New Patients
Please ensure these forms are filled out before your scheduled appointment. If you haven't completed them beforehand, kindly arrive at least 15 minutes early to complete them in person.
Indemnification Clause
Patient Medical History and Intake Form
Pre and Post Visit Instructions
Privacy HIPAA Policies
Patient Consent for Photography
Release of Healthcare Information
Store and Forward Telemedicine Information
Filler and Botox Forms
If you have an appointment for filler or Botox services, please click the links below to download the relevant forms.
Filler Services Consent Form
Neuromodulator Form
Collagen PIN Microneedling
General IV Infusion Forms
B12 and Lipotropic Injection Consent Form
Ketamine Forms
Ketamine Informed Consent Form
Ketamine Pre and Post Visit Instructions
Ketamine Patient Tips for Positive Infusions
Concierge Medicine Forms
Concierge Agreement Form
Hormone Replacement Therapy (HRT) Forms
ADAM Questionnaire
Initial Intake Form
Male Informed Consent Form
Patient Testosterone Therapy Form
Supplement Instructions
Workout Instructions
Weight Loss Forms
GLP-1 Informed Consent Form
Vitamin C Infusion Forms
High Dose Vitamin C Consent Form
GPD6 Declination Form
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