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 reviewing the terms of your agreement with our office to provide medical care to you 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.

financial policy

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.

patch testing consent

This form is required prior to scheduling patch testing for evaluation of allergic contact dermatitis