Medical and Cosmetic Dermatology

1715 N George Mason Dr, Suite 406
Arlington, VA 22205
(703) 310-7400

New Patient Paperwork
Please print and fill out these forms before arriving for your appointment as a new patient. Be sure to bring a valid, government issued photo id and all insurance cards you have; these are required for your appointment.

Medical Records Release
This form is used when you would like to request your medical records.

Family and Friends Release
This form is used if you would like to give our office permission to speak to someone other than yourself regarding your personal medical history, office visits, pathology results, etc.

Third Party Release
This form is used when a third party, such as a life insurance company, is requesting your medical records.

Please note that there may be a fee associated with releasing your records; this office policy is listed in our new patient paperwork. A completed form may be faxed, mailed, or dropped-off in person to our office. Please do not email the completed form.

Awards & Accolades
Close Menu
Call Now