Intake form for minors or dependent adults

Acknowledgment  of Receipt of Privacy Practices

​After you have read the Privacy Practices statement below, print out this acknowledgment form, initial and sign it. Bring it with you to your first appointment.

Release form for transfer of medical records

(please let the staff know that you have had records forwarded to us when you make your appointment).

New Patient Forms

We will need for you to bring your insurance card, a photo ID and a list of any medications that you take, including eyedrops and skin creams. If you are concerned about possible reaction to any products that you use, please bring all the products that you use so that we can read the ingredients on the labels.

You may download and print any of the forms below so that you may fill them out in advance of your appointment in order to speed your check-in.

If you are a parent or legal guardian who wishes for the dependent to be seen without you or to be seen with another caretaker such as a nanny, please print out the form below and sign it giving us the authority to treat your dependent.

A copy of the Notice of Privacy Practices is in the image collection in the column to the right. It will also be available in the office. There is a form on this page which you can copy, initial and sign in advance of your appointment. This merely acknowledges that you understand the privacy policy. This is the standard policy for all medical practices.

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Greenbrae Dermatology