Dermatology Patient Forms

Patient's information

Name

First

Last

Date of Birth

Gender

Marital Status

Phone Number

Email Address

Address

City

State/Province

Zip/Postal

Insurance

Insurance Company

Group

Policy Holder Name

The relationship of the policy holder to you?

Date of Birth of Policy Holder

Insurance Phone Number

Insurance Address/ POBox

City

State/Province

Zip/Postal

Does your insurance require referral or pre-authorization (if yes, please contact your PC and email us the insurance approval for your referral/ PA. Please keep in mind that if your insurance requires this paperwork and it is not submitted prior to your visit with the Specialist (dermatologist), your insurance will not cover this visit.

Upload ID and Insurance Card

Maximum file size: 33.55MB

COVID-19 Screening Questionnaire

Are you vaccinated?

Yes

Have you traveled within the last 14 days?

YesYes

Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?

YesYes

Have you experienced any cold or flu-like symptoms in the last 14 days (fever, cough, shortness of breath or other respiratory problem)?

YesYes

Patient Name

Date

PATIENT PHARMACY CONSENT FORM

Name of Pharmacy

Patient Name

Pharmacy Phone Number

Address of Pharmacy

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 hrs: $50

Cosmetic Appointments(injectables- botox, filler, kybella, laser treatments, PRP) less than 24 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.

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Patient Forms

Patient Forms

Patient's information

Medical History

Insurance

COVID-19 Screening Questionnaire

PATIENT PHARMACY CONSENT FORM

NO SHOW AND CANCELLATION POLICY

About

Services

Patients

Contact

Let’s talk.

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Patient Forms​

Patient Forms

Patient's information

Medical History

Insurance

COVID-19 Screening Questionnaire

PATIENT PHARMACY CONSENT FORM

NO SHOW AND CANCELLATION POLICY

About

Services

Patients

Contact

Let’s talk.

Patient Forms