Patient Information and Forms

PATIENT INFORMATION AND FORMS

Welcome to Dermatology Associates! Thank you for choosing us as your skin's health-care providers!!

Patient Forms

Whether you are a new or a returning patient to Dermatology Associates, please assist us in making your visit as uncomplicated and enjoyable as possible!!

For your convenience, we have supplied all required patient forms in PDF format available for download.

Prior to your appointment, please take time to download and complete all necessary paperwork provided below. (Please note: patients who have visited before, but have not been seen for 3 or more years are considered to be new patients.)

You can also submit all forms online with your MyChart account. Please contact us for your MyChart user account login details.

Registration Form.pdf

Medical History Intake Form.pdf

Patient Welcome Form.pdf

Patient Intake Questionaire.pdf

Patient Release of Information Form

HIPAA Consent Form

Appointments

Patients under the age of 18 must be accompanied by a parent or documented legal guardian for their first appointment. After the initial visit, you may sign an Authorization to Treat a Minor form that will allow us to see your child in your absence for follow-up care appointments. This Authorization to Treat a Minor form is located on the Dermatology Associates, Inc. Registration form.

Cancellations:

If you cannot keep your appointment, we ask that you cancel office visits 24 hours in advance and surgical visits 48 hours in advance. There will be a $50.00 charge for any missed office visit or cosmetic appointment and a $75.00 - $200.00 charge for any surgery appointment not cancelled. These charges are the patient's responsibility and cannot be billed to your insurance company.

Insurance Information:

For information regarding the insurance providers we currently accept, please download the New Patient Welcome Form located above.

Bring to your Appointment:

Your Insurance Card(s). Please note: if you do not bring your insurance card(s), you will be considered Self-Pay.
Listing of any medications, including any vitamins and herbal supplements, that you may be taking.

How to Mail Forms

If you have decided to mail these forms in ahead of your scheduled appointment date, please ensure that you mail these forms directly to our Winchester location on Amherst Street in order to ensure timely processing:

Dermatology Associates

1514 Amherst Street

Winchester VA 22601