Please download and fill out this paperwork before your first appointment with us. We look forward to working with you!
New Patient Paperwork
Special Programs & Patient Financing
CareCredit
The CareCredit credit card makes it easy to access care without delay. CareCredit is the credit card exclusively for healthcare services. With no up-front costs and no pre-payment penalties, CareCredit lets you pay over time and frees up cash and credit cards for the other things you want or need. CareCredit offers monthly payment plans for healthcare procedures not commonly covered by insurance, including dental treatments. Apply today.
LendingClub
LendingClub connects borrowers with investors through their online marketplace. LendingClub screens borrowers, facilitates the transaction, and services the loans. This allows borrowers to receive loans to consolidate debt and finance major purchases. If you’re interested in exploring financing for your cosmetic or restorative treatment plan, visit their website to apply.
ALASTIN Skincare
Experience the fastest growing professional skincare line. ALASTIN Skincare has developed two product lines, Procedure Enhancement Systems which support rejuvenating procedures, and Restore and Renew daily skin care products. Our office provides both lines to our patients and we are here to assist you in developing your custom skin care regimen. Schedule a free consultation to learn more about what we recommend for your skin.
Botox Savings Program
Save Money With the BOTOX® Savings Program. See if you are eligible for help with your out-of-pocket treatment costs. Most insurance plans cover the cost of BOTOX® treatment. The BOTOX® Savings Program can help commercially-insured patients save on out-of-pocket costs for BOTOX® treatment that are not covered by insurance. Learn whether you are eligible today.
Brilliant Distinctions Program
Earn points on participating Brilliant Distinctions® treatments, including Botox, Juvederm and Kybella, with Dr. de Jongh. Redeem your points for savings on future purchases!
Earn points for savings on products you already use — $10 for every 100 points. Plus, receive a reward on your Brilliant Distinctions® Anniversary. The higher your tier, the greater the rewards – just get in touch with any questions!