Clarkston Dermatology
1-248-620-3376 5701 Bow Pointe Drive
Suites 215 & 217
Clarkston, MI 48346

Patient Forms

Forms

  • New Medical Patient Forms-Adults

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  • New Medical Patient Forms-Minors

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  • New Patient Forms-Medicare Patients

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Miscellaneous

  • Parental Consent for the Treatment of Minors

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  • Agreement for Medical Treatment

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    Agreement for Medical Treatment

    • Consent for Examination and Treatment

    • I understand that medical treatment may be necessary for the patient by Dr. Wendy L. McFalda, Dr. Brian A. Kopitzki, and their assistants and/or associates. I understand the examination procedures will be explained to me and I shall consent to the partial or complete examination. I understand that the examination results will be provided to me with recommendations. The responsibility for any follow‐up examination to check abnormalities found and treated, lies with me and not Dr. Wendy L. McFalda, Dr. Brian A. Kopitzki, and their assistants and/or associates. No guarantee or assurance has been given by anyone as to the results that may be obtained by such treatments. I hereby release my examiner from all responsibility in connection with the examination.

      For patients less than 18 years old, a parent or legal guardian must accompany them to the initial visit, and must sign our parental consent form, giving Dr. McFalda, Dr. Brian A. Kopitzki, and their assistants and/or associates permission for continuing ongoing medical treatment if a parent or legal guardian will not be present. The adult accompanying a minor will be held responsible for the payment of any services that are rendered.

    • E Signature

      Your signature below acknowledges that you have read and have a full understanding of Clarkston Dermatology’s Consent for Examination and Treatment.
    • Drop files here or
    • If you are unable to attach these images at this moment, please email them to us prior to your appointment to ensure a timely check-in process. If you have multiple insurance cards please attach all that apply.

      Drivers License

      patientforms@clarkstonderm.com

      Insurance Card

      insurancecard@clarkstonderm.com
  • New Cosmetic Patient Forms

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