Patient Forms 

Forms for Minors

The Minor Patient Form Packet includes the following forms.

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• Patient Financial Responsibly, Office Billing, and Office Scheduling Policies
  • Explains how charges are handled, including insurance billing, patient responsibility, and payment expectations. It also outlines scheduling policies such as cancellations, no-shows, and appointment timing so visits are managed fairly for all patients.
• General Consent to Treat & Clinic Policies
  • Authorizes our clinical team to provide dermatologic care and outlines general office policies. This consent does not replace procedure-specific or treatment-specific consent forms.
• Privacy Policy & Notice of Privacy Practices (HIPAA)
  • Describes how your medical information may be used and shared, and explains your rights regarding access, confidentiality, and privacy under federal law.
• Minor – HIPAA Authorization to Release Protected Health Information to Authorized Individual 
  • Allows a parent or legal guardian to designate individuals who may receive a minor patient’s medical information, consistent with privacy and guardianship laws.
• Records Release Form
• Medical History and Intake Form
• Consent for Minor Patient Seen Alone
  • Allows a minor patient to be seen without a parent or legal guardian present for appropriate visits, while defining the scope of care, communication limits, and privacy considerations.
• Consent for Minor Patient Seen with Non-Parent Adults
  • Authorizes a designated non-parent adult to accompany a minor patient to an appointment and participate in care decisions within defined limits when a parent or legal guardian is not present.
• Consent to Obtain Patient Medication History (Pharmacy & Insurer Sources)
  • Authorizes access to medication history from pharmacies and insurance sources to help improve medication accuracy, safety, and coordination of care.
• Consent to Participate in Health Information Exchange (HIE)
  • Allows secure sharing of health information with other participating healthcare providers to support continuity of care and reduce unnecessary duplication of testing or services.
• Telemedicine Patient-Elected Consent
  • Confirms your agreement to participate in telemedicine visits when offered. This form explains how virtual visits work, their limitations, and privacy considerations, and clarifies that telemedicine is optional.
• Electronic Communication & Patient Portal Consent and Acknowledgement 
  • Authorizes electronic communication through the patient portal, email, or text messaging when applicable. It outlines appropriate use, privacy considerations, and patient responsibilities when using electronic tools.