Fort Mill Dermatology, LLC

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PATIENT FORMS

Fort Mill Dermatology physicians and staff understand that your time is valuable. In order to make your clinic visit more worthwhile, we’ve included some useful forms that you can download and prepare in advance of your appointment. Please bring your completed forms to Fort Mill Dermatology at the time of your next appointment. Our friendly registration staff will take it from there.  We've also included some helpful informational documents.

 

Patient Registration

Patient Education & Information (new!)

Medical Records Transfer

Directions to our Clinic

 

Forms for other doctor's offices to refer patients to our Clinic (new!)

 

Can't view our forms? Download Adobe Acrobat:

FREE Acrobat Reader Our documents are in PDF format and require Adobe Acrobat Reader.  If you don't have Acrobat Reader, get it here free.

 

 


 

 

PATIENT REGISTRATION

 

This group of forms is necessary for us to see you as a patient at Fort Mill Dermatology.  Please print and fill out these forms completely and bring them in at your first visit.  If you can't bring in these completed forms, we ask that you arrive at least 20 minutes prior to your scheduled appointment to allow time to complete them prior to being seen by our doctors.

If you have seen Dr. Rebecca Smith or Dr. Julie Iannini at their previous Charlotte practices, but not at Fort Mill Dermatology, you will still need to fill out the Patient Registration forms so we can get all of your most current information into our new medical records system.

Standard PDFNew Patient Registration - These are our patient registration forms used by new patients or any patient who has not been seen in our practice for 3 years or more.  Directions to our clinic are also included.
Standard PDFNotice of Privacy Practices (HIPAA) - INFORMATIONAL ONLY - This is our notice of privacy practices. It is similar to the HIPAA form present at any medical facility and explains your privacy rights as a patient in our practice.

 

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PATIENT EDUCATION & INFORMATION

 

 

PDF with form fieldsAtopic Dermatitis - Commonly referred to as ECZEMA. Read about the condition and treatment options.
Standard PDFBleach Baths - Bleach baths can be an effective tool for killing bacteria as well as helping to clear atopic dermatitis.
Standard PDFLiquid Nitrogen Treatment - Liquid Nitrogen is commonly used to treat skin pre-cancers as well as warts, skin tags, and "age" spots.  Some treatments are strictly cosmetic and will not be covered by insurance.  Others, such as skin pre-cancers are generally covered by insurance, but may be subject to deductibles or co-insurance.
Standard PDFMELANOMA Skin Cancer - Of all types of cancer, skin cancer is the most common. There are several types of skin cancer and all can be treated if diagnosed early.  The least common, but most dangerous skin cancer is melanoma.  This document contains some pictures of melanomas that show how it can present in a variety shapes, colors and patterns.
Standard PDFMolluscum - Molluscum are sometimes referred to as "water warts" because they are commonly spread in baths and swimming pools. It is a pox virus that can be treated in a variety of ways.
Standard PDFSunscreen - what to look for - How do you choose a good sunscreen?  This document explains the various ingredients and how to be a smart shopper.  Don't be hung up on high SPF numbers!  The ingredients, formulation and proper application are far more important.
Standard PDFWound Care for Biopsies - Biopsies are performed to accurately diagnose or confirm a diagnosis of a skin lesion.  This is a simple procedure, but proper wound care is important to speed healing and minimize scarring.  The information in this document is given to every patient who gets a biopsy done in our office.

 

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MEDICAL RECORDS TRANSFER

 

Excellent care begins with the doctor having an accurate past medical history.  It is also important for us to have a copy of any biopsy reports, particularly if you have a history of any skin cancers or pre-cancers.

 

Some clinics will transfer records directly to another physician or clinic at no charge.  However, physicians or clinics may charge a "reasonable fee" for the preparation and/or the photocopying of medical and other records.  This is sometimes a per page copy charge or a flat fee that is often $10-15.  Whether or not your physician charges for this service is at the discretion of that office policy.

 

If you need to have your medical records transferred from another medical office to Fort Mill Dermatology, you may want to contact them regarding their office policies or use the form below.  At a minimum, they will require your signature on a release form. 

 

Standard PDFMedical Records Transfer Form - This form may be used to transfer medical records to or from our office.  Fort Mill Dermatology does not charge to fax your medical records directly to another doctor's office. 

 

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