In order to serve you better, we ask you to complete the form below before your schedule appointment.

Patient details

Medical history

Office Policy

By signing this form, I hereby give my consent for Ciocca Dermatology, PA to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided describes such uses and disclosures more completely.) I have the right to review the Notice of Privacy Practices prior to signing this consent. Ciocca Dermatology reserves the right to revise its Notice of Privacy Practices at any time. I understand any charges, copays, coinsurance and deductibles will be collected at the time of service. If I do not sign this consent, or later revoke it Ciocca Dermatology, PA may decline to provide treatment to me. There is a NOSHow fee. All accounts past due will be send to collections, collections fee will apply.

By signing this form I have read and understood all of the office policy. I agree to follow all policies and understand if I don't agree to the office policy I will not be accepted as a patient.