Intake + Patient Forms

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Spend less time in the waiting room by printing and filling out the following four forms. All forms are in PDF format; you will need Acrobat Reader (a free software) to view and print them.

Download Patient Intake Forms

  • Patient Information Form
    This form details your personal information and medical history.
  • Patient Record of Disclosure
    This form tells us how best to contact you and protect your privacy.
  • Notice of Privacy Practices
    This form details how we handle your medical records and your rights concerning these records.
  • Acknowledgment of Privacy Practices
    This very simple form ensures that you have received and read our Notice of Privacy Practices.

Download Skin Care Intake Forms

  • Skin Care Assessment Form
    This form details your personal information and medical history.
  • Skin Care Consultation + Release Form
    This form informs us about specific medical predispositions and confirms your consent to treatment.