Patient Forms
These are the forms you will need for your appointment. We encourage you to download, print and complete them at home to bring to your first appointment. These downloadable patient forms are provided in easy-to-use Adobe PDF format for your personal information security. This is not an online registration process.

The Patient Registration form requests your general information and insurance coverage(s).  This form requires your signature and date on the bottom.

The Medical History form should include the details of current and prior medical conditions, and your current medications.

The Policy Regarding Patient Financial Responsibility/Disclosure page can be read prior to your appointment.  You will be asked to sign and date that form when you arrive for your first appointment.  Our representative will witness your signing.

If you are a Medicare patient, you need to read the Medicare & Medigap form.  Sign and date below the Medicare section of the form.  This authorizes us to handle your Medicare claims.  If you have a secondary insurance, the Medigap section applies to you. Sign and date below this section of the form. This authorizes the processing of claims to go from Medicare directly to that secondary insurance.

Please read the HIPAA Patient Consent Form.  This consent will be signed, dated and witnessed by our representative when you arrive for your first appointment.  Any special permissions you wish to make should be detailed on the bottom of the page.  This section will be signed, dated and witnessed by our representative when you arrive for your first appointment.

If you need assistance completing the forms, we will be happy to assist you when you arrive for your appointment.Affiliated Dermatologists – No one knows skin better.



Copyright 2009 Affiliated Dermatologists, S.C. All rights reserved. Information provided by this website is intended for informational purposes only. Contact our physicians to diagnose and treat dermatological problems.