Patient Forms​

Patient Forms

Please fill out these form to get the chart created and for us to have all information for insurance verification. Our Front Desk Patient Coordinator will get in touch with you within 24 hours after you submit this form. 

Patient Form

Patient's information

Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal

Medical History

Any Allergies?
Any chronic diseases?
Any medications that you're taking currently?
Do you have a tendency to faint?
Are you pregnant, trying to conceive or breastfeeding?
Do you take blood thinners i.e Aspirin, Coumadin..?
Any significant recent surgical history?
Do you smoke?
Do you socially drink?
Is there a family history or personal history of Skin cancer, Eczema or Psoriasis?
Have you had any joint replacements, have stents or a pacemaker?

Insurance

Do you have insurance?
Insurance Address/ POBox
Insurance Address/ POBox
City
State/Province
Zip/Postal

Maximum file size: 33.55MB

COVID-19 Screening Questionnaire

Are you vaccinated?
Have you traveled within the last 14 days?
Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?
Have you experienced any cold or flu-like symptoms in the last 14 days (fever, cough, shortness of breath or other respiratory problem)?

PATIENT PHARMACY CONSENT FORM

At Hudson Dermatology & Laser Surgery we continually strive to enhance your experience and ensure seamless access to medications. We recommend that you use a dermatology-focused pharmacy to streamline the fulfillment of your medications. Manhattan Apothecary is our recommended pharmacy of choice because they provide a stress -free pharmacy experience with the best outcomes when obtaining dermatology prescriptions.
ALL OF YOUR PRESCRIPTIONS WILL BE SENT TO AND DELIVERED TO YOUR DOOR WITHIN 1-2 DAYS.
* can be manually updated per your request

Manhattan Apothecary
147 W 35th St,
New York, NY 10001, USA
(212) 302-0600

NO SHOW AND CANCELLATION POLICY

Dear Patient: Please be advised that as a patient of Hudson Dermatology and Laser Surgery all patients are subject to a "NO SHOW and SAME DAY” cancellation policy and failure to call less than 24 business hours in advance will be charged as follows.
Missed General Dermatology appointment (including virtual): $50

Late cancellation for General Dermatology appointment (including virtual) less than 24 business hrs: $50

Cosmetic Appointments(injectables- botox, filler, kybella, laser treatments, PRP) less than 24 business hrs: $200

Patch Testing: $100

Any Patch Test appointment scheduled for Monday should be canceled by Friday at noon or a fee of $100 will be charged.

Start Over
About
Services
Patients
Contact
483 10th Ave 310
New York, NY 10018
Let’s talk.

Get in touch with us and we’ll reply to your inquiry within a few hours.

Book an appointment
Copyright© 2023 Hudson Dermatology & Laser Surgery
close
Book an appointment
(917) 970-9100