Tucson, Arizona (520) 795-7729
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Forms & Information for Your Medical Visit


1 New patients: Please print, fill out, and bring the New Patient Forms with you to your first visit at our office. Please download the forms below.

2 If you are an existing patient, you may also use these forms to update your information. 

3
Please arrive 15 - 20 minutes early for your paperwork to be processed and to keep your appointment running on time.  

4 Please bring your Photo ID and Insurance Card.

5
For a list of Insurances accepted,
click here.

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New Patient Form
Medical History Form

OPTIONAL FORMS
Registration
HIPAA / Advance Directive
Credit Card On File Agreement
Cosmetic Questionnaire

If the patient is
under 18 years of age:
Please download and complete this form:
Consent for Treatment of Minor

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POLICIES:
Understanding our commitment to you and your financial responsibility to us is an essential component to establishing and maintaining a strong patient/practice relationship. In order to achieve this, we offer the following information regarding our office policies: Click Here

PAYMENT:

FORMS OF PAYMENT ACCEPTED:
Cash
Personal Checks
Debit Cards (with a Visa logo)
Visa, Mastercard, American Express, & Discover
CareCredit - Pay Online Here







NO SHOW OR CANCELLATIONS:

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Section 1557 Nondiscrimination Statement
Pima Dermatology, PC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.  Pima Dermatology, PC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
To learn more, please click here.

Patient Bill of Rights and Responsibilities
Patients have the right to considerate and respectful care. To read our Patient Bill of Rights and Responsibilities, please click here.

HIPAA Notice of Privacy Practices
This Notice of Privacy Practices describes how we, our Business Associates and their subcontractors, may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law.To read the Notice of Privacy Practices in full, please click here. 

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