New Patient Info & Forms

New Patients are required to review or complete several forms.  These forms are listed below for patients to print, review and fill-out.  Please bring all completed forms to your first visit.

For complete skin exams: No self tanner applied several days before your appointment so moles can be clearly seen.  And please no nail polish so your nails can also be checked for skin cancer.

**Please also bring your insurance card + picture ID to your appointment.  Insurances accepted:

Aetna, *Blue Cross Blue Shield, State Health Plan of North Carolina (BC/BS), Cigna, United Healthcare, Wellpath, Coventry.

*Please note, we do NOT accept BCBS Blue Value Plan (prefixes are YPV, YPJ, YPL).  We also do not accept Medcost – Humana – Blue Local – Tricare – Medicaid and now any  new Medicare patients.

If your insurance company is not listed above, please feel free to contact our office for the most recent plan participation information.

Waiting List:

If you would like to be seen sooner than your appointment please ask our scheduling staff to put you on the waiting list and you will be called as soon as any cancellation appears.


Patient Information Form

Medical History Form

Skincare Questionnaire

Notice of Privacy Act (please read, but do not need to print)

Acknowledgement of Privacy Act Form

Designated Individuals Authorization Form

New Age Dermatology Financial Policy

Authorization for Treatment of a Minor Form (if new patient is under 18 years of age)