Patient Forms

It is very helpful for Dr. Chiu to have information about your prior skin health history. Please download and fill out the Medical Record Release Form and send/fax it to your previous physician.

Click to download: Medical Release Form

If you need our records sent to another office, please download and fill out the form below.

Click to download: Medical Release Form

Prior to your appointment please download and fill out the Insurance, Privacy Communication and HIPPA Forms below. Please call prior to your appointment  to verify that we have received your records. This will enable Dr. Chiu to provide you with the best possible care at the time of your visit. Thank you!

Click to download: Patient Intake Form

Click to download: Patient Office Policy

Click to download: Signature Sheet

Click to download: HIPAA

Click to download: Cancellation Policy

Click to download: Privacy Policy

If you were a patient of Dr. Chiu’s at Pacific Dermatology & Cosmetic Center, fax the form to:


Please call them at 206.859.5777 to make sure the form was received.

If you were a patient of Dr. Chiu’s at Virginia Mason, please visit their website for instructions on obtaining your records: Virgin Mason: Medical Records



Skin Resurfacing Solutions
Fractional laser treatment can smooth the surface of your skin to offer you excellent results and a minimal downtime.
Lip Enhancement Solutions
Plumping up your lips is an easy way to improve your smile, whether your lips have thinned with age, or you’ve just always wished for fuller lips.
Darker Skin Solutions
I have the laser and cosmetic treatment know how to treat the unique challenges of patients with darker skin colors.
Bellevue Laser & Cosmetic Center