Patient Resources2026-04-29T09:58:16-04:00

Patient Resources

West Michigan Dermatology & The Skin Revitalizing Center

We believe exceptional customer care begins before you arrive at our office. That’s why we provide all the necessary forms and resources to you ahead of time.

Patient Forms

If you are a new patient, you will receive a link through your phone, which will allow you to complete all the paperwork online. If you would prefer to print your paperwork and fill it in, please see the list below.

Financing Options

We are pleased to offer flexible financing options to help you manage your healthcare expenses. We now accept Cherry and Care Credit for all our services, making it easier for you to get the care you need. Click the links below to learn more and apply today.

Financial Policy

We are committed to providing you with the highest level of care and with exceptional service anytime you walk through our doors. Therefore, transparency about our policies and a mutual understanding between us and our patients is vital. We kindly request that you familiarize yourself with the policy below and encourage you to reach out to one of our staff members to connect you with our office manager if you have any questions.

Keeping your appointment is important for many reasons. It allows for your continuation of care especially for procedures which require timeliness between treatments such as laser hair removal, micro- needling or tattoo removal. It also ensures that the clinic runs on time for the day. Should you need to cancel or reschedule your appointment, we respectfully require a 24-hour notice.

Scheduling for certain appointments such as Sculptra, miraDry and RF microneedling will require a $100 deposit. This amount will be refunded when you come for your appointment. Cancelling within 24 hours of your appointment or failing to show up for your appointment will result in this amount being forfeited. This deposit will be collected even if your treatment is part of a package or is prepaid.

After two cancellations and/or one no show, we will require a debit card to be kept on file before we schedule any upcoming appointments for you. A hold fee of $50 will be charged to your card in order to reserve your next appointment. The fee will be applied to your service (or refunded if you have a prepaid service and you keep your appointment).

If you no-show to your appointment, the following fees will be assessed when you attempt to schedule your next appointment. These fees will be applied to your service IF you show up for your appointment.

  • For non-laser appointments: $50
  • For laser appointments: $50 – $100 depending on the nature of your appointment
  • For MiraDry: $200
  • For SecretPro treatments: $200

Non-compliance with instructions for your appointment will also incur a charge similar to no-show fees. Examples of non-compliance are:

Not shaving the area to be treated prior to a laser hair reduction appointment.

Arriving at your laser appointment with tanned or sun exposed skin. In order to avoid the risk of permanent damage to your skin, we will not use a laser to treat any (even minimally) tanned or sun exposed skin.

These requirements are discussed at your consultation, and at the time you make the appointment, and they are also listed in your reminder alerts and emails.

If you are running late to your appointment, please call and notify our front desk staff. Our providers will do their best to accommodate you. If you are more than 10 minutes late, please know that your appointment may need to be rescheduled. If you are more than 10 minutes late more than twice, we will require a debit card to be stored on file before scheduling any additional appointments for you. A hold fee of $50 will be charged to your card in order to reserve your next appointment. The fee will be applied to your service (or refunded if you have a prepaid service and you keep your appointment).

Due to the nature of services provided in The Skin Revitalizing Center, packages for treatments are quite common. When you purchase a package, please be mindful of the following:

  1. You may “swap” your package for another service with comparable value. You will be required to pay a price difference if there is one.
  2. No refunds will be given on unused package services.
  3. Packages expire two years from their date of issue.
  4. Under certain circumstances, we will allow for the cancellation of a package after it has been partially redeemed. Please be aware that determining the amount to be refunded will be done by assessing all redeemed treatments at their full price and not at their discounted package price. You will be refunded the difference.
  5. Most of our services are sold after an in-depth skin consultation, therefore, and to ensure patient safety, patients may not share portions of their pre-purchased package with others.
At The Skin Revitalizing Center, we stand by the products we carry. If you need to return a product, please read the following guidelines:

  • Skincare products that are unopened and in their original packaging may be returned within 30 days of purchase for a full refund. Please bring your receipt.
  • Skincare products that are defective and within their expiration date, may be exchanged within 14 days of purchase for the same product. Please bring your receipt.
  • Skincare products that are expired are ineligible for returns under any circumstances.

We are unable to offer exchanges or refunds due to allergic reactions or skin incompatibility. Known ingredients such as Retinol or Glycolic Acid, may cause allergic reactions to sensitive skin. Please consult with a member of The Skin Revitalizing Center if you have any concerns about allergic reactions.

If you purchase a product online and wish to return it, you are responsible for all related shipping charges.

  • All deposits for skincare services are non-refundable. If a patient pays a deposit to secure a promotional price on a package and ultimately decides not to receive the service, they may apply the deposit toward a different product or service.
  • Deposits made to secure an appointment will be refunded if the patient comes to their appointment, unless the patient has an outstanding balance. In this case, the deposit amount will be applied to the patient’s outstanding balance.

Pay Bill

Make Your Online Payment

For questions regarding your bill, please call our office at (616) 257-3344. To make an online payment, please click here.

Notice of Privacy Practices

Please Review Carefully

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION.

Protected health information (PHI), about you, is maintained as a written and/or electronic record of your contacts or visits for healthcare services with our practice. Specifically, PHI is information about you, including demographic information (i.e., name, address, phone, etc.), that may identify you and relates to your past, present or future physical or mental health condition and related healthcare services.

Our practice is legally required to maintain the confidentiality of your PHI, and to follow specific rules when using or disclosing this information. This Notice describes your rights to access and control your PHI. It also describes how we follow applicable rules when using or disclosing your PHI to provide your treatment, obtain payment for services you receive, manage our healthcare operations and for other purposes that are permitted or required by law.

Following is a statement of your rights, under the Privacy Rule, in reference to your PHI. Please feel free to discuss any questions with our staff.

You have the right to receive, and we are required to provide you with, a copy of this Notice of Privacy Practices – We are required by law to follow the terms of this Notice. We reserve the right to change the terms of the Notice, and to make the new Notice provisions effective for all PHI that we maintain. We will provide you with a copy of our current Notice if you call our office and request that a copy be emailed or sent to you in the mail, or ask for one at the time of your next appointment. The Notice will also be posted in a conspicuous location in our practice, and if such is maintained, on the practice’s website.

You have the right to authorize other use and disclosure – This means we will only use or disclose your PHI as described in this Notice, unless you authorize other use or disclosure in writing. For example, we would need your written authorization to use or disclose your PHI for marketing purposes, for most uses or disclosures of psychotherapy notes or substance use disorder counseling notes, or if we intended to sell your PHI. You may revoke an authorization, at any time, in writing, except to the extent that your healthcare provider, or our practice has taken an action in reliance on the use or disclosure indicated in the authorization.

You have the right to request an alternative means of confidential communication – This means you have the right to ask us to contact you about medical matters using an alternative method (i.e., email, fax, telephone), and/or to a destination designated by you (i.e., cell phone number, alternative address, etc.). You must inform us in writing, using a form provided by our practice, how you wish to be contacted if other than the address/phone number that we have on file. We will follow all reasonable requests.

You have the right to inspect and obtain a copy your PHI* – This means you may submit a written request to inspect or obtain a copy of your complete health record, or to direct us to disclose your PHI to a third party. If your health record is maintained electronically, you will also have the right to request a copy in electronic format. We have the right to charge a reasonable, cost-based fee for paper or electronic copies as established by federal guidelines. We are required to provide you with access to your records within 30 days of your written request unless an extension is necessary. In such cases, we will notify you of the reason for the delay, and the expected date when the request will be fulfilled.

You have the right to request a restriction of your PHI* – This means you may ask us, in writing, not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. If we agree to the requested restriction, we will abide by it, except in emergency circumstances when the information is needed for your treatment. In certain cases, we may deny your request for a restriction. You will have the right to request, in writing, that we restrict communication to your health plan regarding a specific treatment or service that you, or someone on your behalf, has paid for in full, out-of-pocket. We are not permitted to deny this specific type of requested restriction.

You have the right to request an amendment to your protected health information* – This means you may submit a written request to amend your PHI for as long as we maintain this information. In certain cases, we may deny your request.

You have the right to request a disclosure accountability* – You may submit a written request for a listing of disclosures we have made of your PHI to entities or persons outside of our practice except for those made upon your request, or for purposes of treatment, payment or healthcare operations. We will not charge a fee for the first accounting provided in a 12-month period.

You have the right to receive a privacy breach notice – You have the right to receive written notification if the practice discovers a breach of your unsecured PHI and determines, through a risk assessment, that notification is required.

Treatment
We may use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party that is involved in your care and treatment. For example, we would disclose your PHI, as necessary, to a pharmacy that would fill your prescriptions. We will also disclose PHI to other healthcare providers who may be involved in your care and treatment.

Payment
Your PHI will be used, as needed, to obtain payment for your healthcare services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the healthcare services we recommend for you such as, making a determination of eligibility or coverage for insurance benefits.

Healthcare Operations
We may use or disclose your PHI as needed to support the business activities of our practice. This includes, but is not limited to business planning and development, quality assessment and improvement, medical review, legal services, auditing functions and patient safety activities.

Special Notices
We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. We may contact you by phone or other means to provide results from exams or tests, to provide information that describes or recommends treatment alternatives regarding your care, or to provide information about health-related benefits and services offered by our office.

We may contact you regarding fundraising activities, but you will have the right to opt out of receiving further fundraising communications. Each fundraising notice will include instructions for opting out.

Health Information Organization
The practice may elect to use a health information organization, or other such organization to facilitate the electronic exchange of information for the purposes of treatment, payment, or healthcare operations.

To Others Involved in Your Healthcare – Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person that you identify, your PHI that directly relates to that person’s involvement in your healthcare. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine, based on our professional judgment, that it is in your best interest. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care, of your general condition or death. If you are not present or able to agree or object to the use or disclosure of PHI (e.g., in a disaster relief situation), then your healthcare provider may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the PHI that is necessary will be disclosed.

Other Permitted and Required Uses and Disclosures – We are also permitted to use or disclose your PHI without your written authorization, or providing you an opportunity to object, for the following purposes: if required by state or federal law; for public health activities and safety issues (e.g. a product recall); for health oversight activities; in cases of abuse, neglect, or domestic violence; to avert a serious threat to health or safety; for research purposes; in response to a court or administrative order, and subpoenas that meet certain requirements; to a coroner, medical examiner or funeral director; to respond to organ and tissue donation requests; to address worker’s compensation, law enforcement and certain other government requests, and for specialized government functions (e.g., military, national security, etc); with respect to a group health plan, to disclose information to the health plan sponsor for plan administration; and if requested by the Department of Health and Human Services in order to investigate or determine our compliance with the requirements of the Privacy Rule.

Prohibited Uses/Disclosures
Substance use disorder treatment records received from Part 2 programs, or testimony relaying the contents of such records, will not be used or disclosed in any criminal investigation, to initiate or substantiate criminal charges, or in civil, criminal, administrative or legislative proceedings against you without your authorization or a court order with accompanying subpoena or similar legal mandate compelling disclosure.

PHI that is potentially related to reproductive health care is prohibited from being disclosed for purposes of investigating or imposing liability on any person for the mere act of seeking, obtaining, facilitating, or providing lawful reproductive health care.

Attestation
Any person requesting disclosure of PHI potentially related to reproductive health care for purposes of health oversight, law enforcement, judicial or administrative proceedings, or about decedents to coroners or medical examiners will be required to submit an attestation signifying that the PHI will not be used for prohibited purposes (see above section).

You have the right to complain to us, or directly to the Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated by us. We will not retaliate against you for filing a complaint. You may ask questions about your privacy rights, file a complaint or submit a written request (for access, restriction, or amendment of your PHI or to obtain a disclosure accountability) by notifying our Privacy Manager at (616) 395-9379.

Patient Resources

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The Skin Revitalizing Center

FAQs

What is your Patient Financial Policy?2025-06-12T15:01:38-04:00

You can learn about our Patient Financial Policy on our Patient Resources page. If you have any questions, please contact us.

What is the late policy for appointments at the Skin Revitalizing Center?2025-06-12T14:55:03-04:00

Our policy is to request that you be on time for your appointments. If you are more than 10 minutes late, you may be asked to reschedule. This policy is in place to ensure that your provider is able to give each patient the attention and service they deserve while allowing time for proper sanitation and preparation between appointments. Click the link to learn more about our Appointments & Cancellation policy. Thank you for helping us stay on time!

I have some significant acne on my face and body. Can one of your estheticians treat me?2024-09-30T16:18:28-04:00

If you have significant acne that has not been evaluated by a medical professional, we recommend that you schedule an appointment with one of our medical providers.

Once you have made some progress through the medical treatment plan they create for you, The Skin Revitalizing Center can help you achieve maximum benefit with a proven regiment of skincare treatments and products.

Do I need to wear sunscreen in the winter?2024-09-08T14:57:56-04:00

Yes, it is important to wear sunscreen, even in the winter. UVA rays are present at the same strength all year long. Wearing sunscreen is a great way to protect yourself from the rays that can cause skin cancer and wrinkles. Shop our sunscreens online or in person today!

Do treatment packages expire?2024-09-17T15:32:56-04:00

Yes, the treatment packages expire two years after purchase.

Shop Online

Find all of your favorite skin care products online with West Michigan Dermatology. We can ship them directly to your house!

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