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New Patient Forms

Joseph Muccini, MD, FAAD Contents New Patients

 

New Patient Forms

 

Please click on the links below to access and then print out our new patient forms. Please complete these forms in advance and then present them to reception staff when you arrive for your first visit.

 

Registration Form

Medical History Form

Medical History Form – Drug List Additional Sheet (Optional As Needed)

Authorization for Release of Information (HIPAA)

HIPAA Notice of Privacy Practices

Please note:  If you already have a handwritten or typed medication list, you may write “see attached” in the medication list section of the medical history form, and then bring your existing medication list along with the above forms to our office.  Thank you for helping us make your first visit as efficient as possible!

 

 

Types of Payment Accepted

Payment for services is expected at the time services are rendered.  We offer several payment options. In addition to check or cash we also accept MasterCard, Visa, American Express, and Discover. Most major insurance plans accepted for medical dermatology procedures.

We also accept Care Credit.

If your insurance plan requires a referral to a dermatologist, please see your primary care physician first.