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 and signed prior to your appointment. You can fill out, sign and submit forms on any computer or smartphone.

NEW PATIENT FORMS

Click on a Form below. Fill out the form, sign the form with your finger or using your mouse. Some forms have multiple pages; be sure to fill out second and third pages if a form has multiple pages. Once all pagers are filled out, click the SUBMIT button to automatically send your completed form to our offices. All information shared is encrypted and HIPAA secure. Be sure to complete all FIVE (5) NEW PATIENT FORMS.


MEDICAL HISTORY FORM

RELEASE OF INFORMATION AND FINANCIAL POLICY

EMAIL AND TEXT MESSAGING CONSENT FORM

MEDICAL NECESSITY POLICY

COPY OF PICTURE ID AND INSURANCE ID

ADDITIONAL FORMS


You only need to fill out these forms if requested specifically from our office staff. Text us at 817-755-5542 to see if you need to fill out any of these forms.

PROMPT PAY – SELF PAY FORM (SELF-PAY RELEASE FORM TO ARLINGTON CENTER FOR DERMATOLOGY)

MINOR CONSENT OR MEDICAL POWER OF ATTORNEY (MPOA) FORM (FOR PATIENTS UNDER THE AGE OF 18 OR PATIENTS UNDER CARE OF ANOTHER)

MEDICAL INFORMATION RELEASE FORM (TO REQUEST TO SEND YOUR MEDICAL RECORDS FROM ARLINGTON CENTER FOR DERMATOLOGY TO ANOTHER DOCTOR)

MEDICAL INFORMATION RECEIVE FORM (TO HAVE SENT YOUR MEDICAL RECORDS FROM ANOTHER DOCTOR TO ARLINGTON CENTER FOR DERMATOLOGY)

You can fill out these forms online or download any of these additional forms and return completed and signed via email (frontoffice@acderm.com) or fax (817-385-7568) if requested by our office staff.

Copyright © 2024 . All rights reserved. Website Designed by Gott Marketing