Please fill out these forms and bring them with you when you come for your appointment or email them back to us at [email protected].
As you know, email is not secure and has a number of risks that you should think about. Your use of email is an acknowledgment of this insecurity and your acceptance of the risk. If you do not want to email your forms, you may fax them to the office at (704) 295-0005 or mail them to 2615 East 7th Street, Charlotte, NC 28204.
This form needs to be filled out and signed if:
- you are a new patient
- you have had any changes since your last appointment (i.e.: medical history changes, address changes, etc.)
- you have not been seen at the practice in the past six months.
Forms to review before your appointment:
Please review this form before your first appointment. You will sign for this via electronic signature while present at the office.
Please review the following forms before your first appointment. You will sign for both of these forms on the Registration Form (see above).
Please review this form before your Mohs surgery appointment, sign at the bottom of the page, and bring to your appointment.
Navigating the Patient Portal After your appointment:
Here are some helpful tips and instructions for navigating the patient portal after you have an appointment at our office.
Medical Record Request Form
If you need to request a copy of your Medical Records for transition of care or other purposes, please complete the Standard Authorization of Use & Disclosure of PHI Form and fax or mail back to our office so we may fulfill your request.