Please be advised that if you are a new patient, refer to the email link we have sent you when we scheduled your appointment. Please verify your email address through the link and follow the steps to create your patient portal.
The following forms are only to be used in the event that you cannot access the patient portal and the staff has instructed you to complete these forms.
Patient Registration Form
Please use the form below to fill out your new patient demographic information, medical history, and review our patient policies. Please note that the following forms are only to be used in the event that you cannot access the patient portal and the staff has instructed you to complete these forms.
Patient Policies
This form is to certify that you have read, understood, and agreed to New Jersey Dermatology and Aesthetics Center’s policies on appointments, patient insurance responsibilities, minor patients, referrals, insurance inquiries, and credit card on file.
Insurance Signature on File
This form is to certify that the insurance information you have provided is correct and authorize your insurance benefit payments to Dr. Zain Husain
HIPAA Authorization
This form is to authorize the New Jersey Dermatology and Aesthetics Center to obtain, keep, and disclose protected health information to other covered entities in order to diagnose and treat
Authorization for Medical Treatment
This form is to authorize the use of anesthetics, medications, and other procedures including but not limited to biopsies, Kenalog injections, and liquid nitrogen if deemed necessary by your provider
Consent to be Photographed
This form is to allow medical photographs to be taken for your medical record to be used for your evaluation. Medical photos include but are not limited to, patient photo for their chart, images of areas of concern, etc.
Convenient Pay Agreement
This form is to certify that you have read, understood, and agreed to our credit card on file policies.
Informed Consent for Telemedicine
This form is to certify that you have read, understood, and agreed to our credit card on file policies.
DOWNLOAD AND PRINT NEW PATIENT FORMS
Please print, download, and complete forms ONLY if you cannot access the patient portal and cannot complete the electronic forms above. You can scan and e-mail the forms to frontdesk@njdermcenter.com. If you are unable to scan and email these forms, you can arrive 15 minutes early to your appointment and bring them with you so our staff can assist you.
