For Patients

NEW PATIENT FORMS



As a new patient to our clinic, we ask you to provide us with information about your medical history, insurance options, and contact information. We also ask that you acknowledge and accept our office policies. Below is the full list of forms you will need to complete, as well as additional forms you may have a need for.

In order for us to ensure our timely schedule and to make your experience at Arlington Center for Dermatology as enjoyable as possible, please have all of the necessary forms filled out prior to your appointment. You may download, print and complete the following forms, and once all of the forms have been completed and signed, you may either fax them to 817-385-7568, mail them to us at least 1 week in advance, or just bring them with you to your next appointment.



NEW PATIENT FORMS


MEDICAL HISTORY FORM

RELEASE OF PROTECTED HEALTH INFORMATION

FINANCIAL POLICY

NOTICE OF PRIVACY PRACTICE

EMAIL AND TEXT MESSAGING CONSENT FORM

Download all of these NEW PATIENT FORMS and return completed and signed via email (frontoffice@acderm.com) or fax (817-385-7568) to assure your NEW PATIENT Appointment proceeds without delay.

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