Stacia Poole MD, LLC Dermatology
Stacia Poole MD, LLCDermatology

Patient Forms

The forms below are available to print, complete, and bring or mail to the office for your appointment or to consent for release of your records.

Don't forget to bring your insurance information with you

In order to register and treat you promptly, we request that our patients bring their current insurance information with them for each visit.

We accept most types of health insurance. Please contact us for further details.

HIPAA Authorization for Release of Records
2020-08-17 HIPAA auth for release of rec[...]
Adobe Acrobat document [75.5 KB]
Health History
health history form updated1 - SP.pdf
Adobe Acrobat document [39.2 KB]
Assignment of Insurance Benefits
Patient information - assign benefits.pd[...]
Adobe Acrobat document [20.0 KB]
Emergency contact form - Dr. Poole
Emergency Contact Form, HIPAA.pdf
Adobe Acrobat document [25.6 KB]
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