Patient Handouts

The following documents are for the information or convenience of our patients. New patients may want to download forms so they can complete them prior to their initial office visit. The files for each document are in PDF format. Should you not have Acrobat Reader, it can be downloaded freeĀ here.

Medical Record Form

This medical record release form will allow a patient to have their records transferred to or from Brentwood Dermatology.

Download this form

New Patient Registration

This form requests demographic, insurance, and medical history information from our new patients. This information is necessary for us to file insurance and allows us to treat our patients optimally.

Download this form

Healthcare Waiver Form

This form allows us to give treatment to a patient whose required Primary Care Physician referral form has not reached our office.

Download this form

Cosmetic Procedure Waiver Form

By signing this document, a patient having a cosmetic procedure signifies that they will pay for the procedure and that they understand that no insurance claim will be filed by our office.

Download this form

Spider Vein Treatment Information

This document gives information about sclerotherapy and its possible complications as well as giving instructions about care after the procedure.

Download this form

Photoderm Information and Consent Form

This document explains photoderm and its possible complications. By signing it, the patient signifies that they have sufficient understanding to give their informed consent to undergo the procedure.

Download this form

Liquid Nitrogen Treatment Information Form

This form discusses liquid nitrogen treatment of skin lesions and details the changes in the skin which will be noted by patients after they have received this treatment.

Download this form

Brentwood Dermatology Notice of Privacy Policies

This document spells out in comprehensive fashion the rules that our office follows in handling confidential information pertaining to our patients and their care.

Download this form