Pre-registration Forms

Whether you are a new or existing patient, Harrisonburg Dermatology requires a small effort on your part so that we can meet the many needs of an integrated healthcare system. You may bring your forms to your appointment or email them to our secure email at [email protected]

Forms to be completed annually:

PHI Annual Demographic Information Form

  • Patient Agreement – The intent of this agreement is to inform you of Harrisonburg Dermatology’s financial policies and Notice of Privacy Practices (HIPAA).

Patient Agreement Form

Forms to be completed as needed:

  • Request for Medical Records Release Form – Whether you are requesting forms be sent to another provider or requesting forms be sent to Harrisonburg Dermatology, your written authorization is required.

Request for Medical Records Release Form

Telemedicine Consent Form

Consent to Treat a Minor Form