Forms:

For your convenience, we have provided forms that can be downloaded, printed and completed prior to your appointment at Saybrook Dermatology. All forms are Adobe Acrobat files. Get the FREE Adobe Acrobat Reader

• HERE

New Patient Forms

Medical Appointment
Please bring the following forms:

1. New Patient Information Form
2. Authorization to Release Info (Contact Consent) Form
3. History & Intake Form
4. MultiPlan Waiver (for United Healthcare/Oxford only)

Transfer of Records

• Authorization for the Release of Medical Records

HIPAA

• Privacy Practices: Summary of Notice
• Privacy Practices: Full Notice

Medical Care

• Biopsy After Care
• Cryosurgical Wound Care
• Pre-Operative Instructions
• Post Operative Instructions
• Permission to Evaluate and Treat (Minor)
• Treatment of Actinic Keratoses with Fluorouracil Cream (i.e. 5FU, Fluorouracil, Efudex, Tolak)
• Cool Down Instructions

TELEHEALTH VISIT

• Consent to Telehealth Visit