Forms

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At the Center for Excellence in Dermatology we understand the need for information about health care and insurance coverage. The following forms will help allow us provide you with the best care possible.

If you are a new medical or cosmetic patient, please complete the forms in the appropriate packet (either the New Medical Patient Packet or the New Cosmetic Patient Packet) and bring them to the office at your scheduled appointment time.

If your last appointment here was less than a year ago, please fill out the Medical History Follow-up form. If your last appointment was over one year but less than three years ago, please fill out the Medical History Follow-up, Office Policies and Notice of Privacy Practices forms. If your last appointment was over three years ago, please fill out the Medical History, Office Policies and Notice of Privacy Practices forms.

If your insurance info has changed since your last appointment, fill out the Insurance Form.

If you have Medicare, fill out the Medicare Policies form in addition to the other required forms.

We look forward to seeing you in the office.

Registration Forms

• New Medical Patient Packet (PDF)
• New Cosmetic Patient Packet (PDF)
• Medical History (PDF)
• Medical History Follow-up (PDF)
• Office Policies (PDF)
• Notice of Privacy Practices (PDF)
• Insurance form (PDF)
• Cosmetic Registration Form
• Medicare Policies form (PDF)
• Records Release Form (PDF)
• Authorization to Disclose Protected Health Information (PHI) (PDF)
• Payment Plan Application Form (PDF)
• Frequently Asked Questions (PDF)