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First Visit Forms

First Visit Forms

Before your first visit, please fill out the following forms and bring them with you to your appointment. In addition to these forms, you will need to bring a photo ID. All payments are due in full at the time of service. 

Patient Acknowledgement and Permissions Form

This is a standard patient form to acknowledge Golden Rule Skin Clinic, P.C. provided you the Summary/Notice of Privacy Practices information. 

Authorization for Release of Protected Health Information Form

This form is intended to release a patient's medical information to another health care provider or 3rd person or party. This is a voluntary form but does allow for cohesive care if medical information is shared between health care providers. 

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Other Important Information

Notice of Privacy Practice Statement

This statement provides information on how Golden Rule Skin Clinic, P.C. maintains the confidentiality of your medical information. 

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