Patient Forms

In order to get the most out of your visit, please remember to bring a list of the medications you are currently taking, as well as any other medical conditions you might have. Please remember your insurance card or proof of coverage, as well as the appropriate form of payment for the co-pay on your insurance. To ensure that Upstate Dermatology participates with your insurance plan, please contact your insurance provider directly.

For your convenience, we’ve included some of the patient in-take forms available below. We welcome you to print and fill out the forms at home prior to your visit, and simply bring them with you to your appointment. If you have any questions, a member of our staff will be happy to help you when you arrive and help you with any sections you may have questions about.

Download patient forms

To view the forms listed below, you will need Adobe Reader. You may download Adobe Reader for free at

New Patient Packet  
Minor Consent Form  
Medical Records Release Form  
Notice of Privacy Practices