• New Patient Demographics Form

  •  - - Pick a Date
  • Phone Numbers

  • Insurance Information

  • Emergency Contact

  • Assignment of Benefits

    Please, initial each line item and sign below
  • For Medicare Recipients Only

  •  - - Pick a Date
  • Clear
  •  - - Pick a Date
  • Privacy Protection

  • The Health Insurance Portability and Accountability Act (HIPAA) requires A Center For Dermatology, Cosmetic and Laser Surgery (Practice) to obtain your authorization to allow communications regarding your protected health information. This authorization gives permission to our staff to discuss your health care with a family member or any other individual that you may designate. It also allows us to leave recorded messages at your home, work, or on your cell phone related to your medical care and treatment, payment, appointment status, or follow-up. Please, list phone number(s) in order of preference for receiving appointment reminders and/or patient care calls:

  • Please, check an applicable option below

  • The Notice of Privacy Practices is available for your review at the office. Please, ask our staff if you wish to obtain a copy for your records.  

  •  - - Pick a Date
  • Clear
  •  - - Pick a Date
  • Should be Empty: