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 free here.
Patient Forms
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.
