Patient Forms

Please be advised that if you are a new patient, to 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 utilize 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 rontdesk@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.

“Dr. Husain is an amazing cosmetic surgeon. He has far exceeded my expectations each time I have had a procedure performed. Dr. Husain is warm, personable, and goes out of his way to answer questions, make suggestions and dispel any concerns I may have. He carefully explains each procedure and always thoroughly reviews the post-operative care. His artistic eye combined with exemplary surgical skills make for a perfect result every visit.”

– Clare Morison

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