Complete the appointment request form and you will hear from us within 1 business day to schedule your appointment!

Forms and Information


 

DOWNLOADABLE FORMS

To save time and make the process more convenient, you can fill out several forms at home before your appointment. Just click on the button below to print out a copy of the form on your printer, fill it out and bring it to your appointment.

Forms are available in Adobe Acrobat PDF format. Please click the link to download the appropriate form:

New Patient Paperwork

REGISTRATION FORM

Patient Registration form

 

 

HEALTH HISTORY (2 PAGES)

View/Download PDF

 

Don't forget to bring your photo ID, insurance card, and prescription card to your first visit!

 

Additional Forms 

 

CONSENT & PRIVACY FORM

View/Download PDF

 

 

PRACTICE POLICIES

View/Download PDF

 

 

PATIENT AUTHORIZATION TO DISCLOSE HEALTH INFORMATION

View/Download PDF

 

 

AUTHORIZATION TO PROVIDE TREATMENT TO MINORS

View/Document PDF

 

 

INSURANCE

Clear Skin Dermatology accepts most private insurance plans as well as Medicare.

CANCELLATION/NO SHOW POLICY

We understand that there are times when an emergency will prevent you from keeping your appointment. In those instances we ask that you notify the office prior to your scheduled appointment time. Should you fail to provide us with this advance notice, the corresponding fee will be charged.

No-show or cancellation with less than 24 hours notice for office visits = $25 Fee

No-show or cancellation with less than 48 hours notice for surgeries and cosmetic procedures = $100 Fee

It is our goal to provide all of our patients with an appointment time that matches their needs, and your cooperation with this policy helps make this possible.

Thank you for your understanding!


EDUCATIONAL RESOURCES

To help you stay informed, listed below are some materials and videos that can help you identify and prevent skin cancer as well as links to the top dermatology websites.

VIDEOS AND FLYERS

Sunscreen Information Flyer (pdf)

Self Exam and Body Mole Mapping Instructions (pdf)

How to apply Sunscreen (video)

How to perform a self exam (video)

WEBSITES

American Academy of Dermatology https://www.aad.org/

American Society for Dermatologic Surgery https://www.asds.net/Public-Resources/

Spot the Spot, https://www.spotthespot.org/

The Skin Cancer Foundation, https://www.skincancer.org/

American Cancer Society, https://www.cancer.org/

Our Locations

Choose your preferred location