Forms and Notices
NEW PATIENT INTAKE FORM
In order to facilitate your first visit, please print and complete this form and bring it to your appointment.
medical records request
If you need a copy of your medical records from Kenwood Dermatology, please complete the medical records release form. If you are requesting a copy for personal use, please allow up to 30 days for processing. A processing fee of $25 will be charged to your account for each separate request.
If you need to have medical records forwarded to Kenwood Dermatology from another office, provider, or hospital, please complete the medical records release form below and forward to the appropriate person.
CONSENT TO TREAT
Our consent to treat policy is available for review prior to your visit.
Our financial policies related to billing and medical insurance are available for review prior to your visit.
consent to treat a minor
If your child will be accompanied to an appointment by a non-legal guardian, we will need a signed and notarized consent form on file.
NOTICE OF PRIVACY PRACTICES
This notice provides information on how we may used your protected health information as required by law under the Health Insurance Portability and Privacy Act of 1996.