New Patient Forms

As a new patient of our clinic, you will need to share with us information about your previous medical history, insurance information, contact information as well as acknowledgment and acceptance of our office policies. Below are all the forms you will need to complete as a patient of our clinic.

In order to ensure a timely schedule and make your experience at Arlington Center for Dermatology as enjoyable as possible, we have made our patient registration forms available online. Prior to your appointment, please download, print and complete the following forms. Once all forms are complete and signed, you may fax them to us at 817-226-7546, mail them to us at least 1 week in advance, or bring them with you to your appointment.

• Medical History Form
• Release of Protected Health Information
• Financial Policy
• Notice of Privacy Practices
• Minor Consent form (for patients under age 18)
• Medical Information Release  form (request to send your medical records from Arlington Center for Dermatology to another doctor)
• Medical Information Receive form (send your medical records from another doctor to Arlington Center for Dermatology)
• Prompt Pay – Self Pay form (Self-pay Release Form to Arlington Center for Dermatology)

You will need all of these forms filled out to begin your visit in our office.