Patient Forms


Dear Patient,


Welcome to our practice. We are pleased that you have chosen us for your healthcare needs. Our goal is to provide you with the best medical care available in our specialty.


To make your registration process easier, the necessary forms are available for download and printing below this paragraph. Please take the time to complete these forms and bring them with you to your appointment. We also need you to bring your driver's license, all your insurance cards, and a list of all medications you are taking. If you do not have a list, please bring your medications with you. Also, if you have an HMO insurance, please make sure you call your primary care physician so they are able to obtain your insurance referral for your appointment. For your convenience, you can view our contact us page to assist you in locating our office.


Please do not wear any makeup, hair spray, or nail polish the day of your appointment, or be prepared to remove it before the appointment. This will allow us to better examine your skin.


Please be aware that office visit copays will be due at the time of service. If you are unable to keep your appointment please call 248-267-5020 to reschedule. Effective December 1, 2006, patients will be charged a $40.00 service fee for missed appointments and cancellations with less than 24-hour notice. We are looking forward to meeting you.




The Staff of Affiliated Troy Dermatologists




>>New Patient Forms

>>Minor Consent

>>Pre and Post Peel Instructions

>>Medical Records Release Request to be sent From Our Office**

**Records being sent to patients require a fee not to exceed $25 (based on # of pages). Records can be sent directly to doctor's office as a courtesy free of charge. Please allow at least 48 hours before contacting the office to inquire about the status of a request after submission.

>>Medical Records Release Request to be sent To Our Office

>>Laser Consultation Paperwork

>>Social Media Consent

>>Patient Care Instructions for Levulan Therapy

>>HIPAA Privacy Notice



To view these forms, you need to have Adobe ReaderĀ®

installed on your computer or device.

Click Here to download the latest version.

HomeStaffAbout UsServicesProductsPatient Education Patient FormsContact Us Site Map