Dermatology Authorization for Treatment and Release Form

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Consent for Treatment

I hereby authorize the dermatology providers at [Practice Name] to perform medical examinations, diagnostic procedures, and treatments necessary for my dermatologic care. This may include:

• Skin examinations and biopsies
• Administration of local anesthetics
• Minor surgical procedures
• Laser treatments (when applicable)
• Medication administration
• Photography for medical documentation

Financial Agreement

I understand that:

1. I am financially responsible for all charges, whether covered by insurance or not
2. Co-payments are due at the time of service
3. Insurance verification is not a guarantee of payment

Privacy Acknowledgment

I acknowledge receipt of the Notice of Privacy Practices and consent to the use and disclosure of my health information for treatment, payment, and healthcare operations.

Photography Consent

I authorize the taking of medical photographs for documentation and treatment planning purposes. These images will be stored securely as part of my medical record.

Authorization

Patient/Guardian Signature: _________________ Date: __________ Witness Signature: ________________________ Date: __________

Emergency Contact

Name: _________________________ Relationship: _____________ Phone: ________________________

Form valid for one year from date of signature unless revoked in writing.