Patient Paperwork


Cosmetic Dermatology

Please Read Before Downloading The Following Forms:

We are delighted you have chosen SHAPE Medical Center for your Cosmetic Dermatology needs. Please complete and return the appropriate forms to our office at the time of your appointment. Included with our new patient forms is a Release of Medical Records Form. Please fill this out and forward it to any medical provider that may have pertinent medical records. Allow adequate time to get your medical records for your visit. Please allow adequate time to obtain your medical records.

Most of the treatments provided at SHAPE Medical Center are cosmetic procedures and not reimbursed by insurance. However, should you desire to submit a claim, please request a bill form from our office at the time of your visit and submit to your insurance attached to the Universal Claim Form

Procedure Fees 

If you are 65 and older, or have Medicare as your insurance, please fill out the Private Medicare Contract

 

All NEW Patients, please print and complete the following forms:

Patient Demographics

Confidential Medical History

HIPAA Notice of Privacy Practices

 

 

Should you desire your SHAPE Medical Records to be sent to another provider, please complete the Authorization to Release Medical Information.

 

Nutrition and lifestyle play an important role in the health of your skin. Many chronic skin diseases are manifestations of inflammation on the skin. Therefore, your inner health is something to be considered. If interested, please read A Message About Nutrition to gain a better understanding of our approach. The Food & Exercise Journal is available if nutrition counseling is desired.

Thank you. We look forward to your visit.

 

 

Cosmetic Dermatology Paperwork

Cosmetic Dermatology Health History Form

Patient Demographics

Release for Medical Information

Release of Medical Records Form

Universal Claim Form

HIPAA Notice of Privacy Practices

Private Medicare Contract

A Message About Nutrition

Food & Exercise Journal