Demographics & Consent Form

Please correct the errors described below.

Welcome to Our Office

Insurance: Provide your insurance card(s) at check-in.

Responsible Party (if patient is under 18):

Practice Consents

Consent for Treatment

You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks involved. This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended and consent to treatment at this office. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions. I voluntarily request a physician and/or other designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

Consent for Test Result Notifications

Notice of Privacy Practices

I acknowledge that I have reviewed the Lower Highlands Dermatology Notice of Privacy Practices and that a copy is available at the reception desk as well as as required by law.

Thank you for choosing Lower Highlands Dermatology for your skincare needs.

Your information will be encrypted.