Patient Forms

at Rajan Dermatology

Registration

Patient medical release of records form.

Records Release

Patient registration, insurance, and records release form.

Notice of Privacy

The Notice of Privacy Practices form describes how patient medical information is used and disclosed and how you, the patient, can have access to this information.

Patient Authorization

The General Patient Authorization form describes our practice policies and payment policies and procedures. It also outlines policies regarding the release of patient information.

Minor Consent

The Minor Consent to Treat form allows the providers in our office to see and treat your child when a parent is not present. All surgical procedures do, however, require a parent to be present.

  • I understand that Protected Health Information (PHI) or sensitive information should not be included in this message.

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