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Patient Forms

If you are a new patient or have not been to the office within the past 12 months, please print, complete and sign our Patient Registration Forms below prior to your visit. You may email to reception@chelseaskincenter.com, fax them to 212-675-0540 or, if scheduled for an IN OFFICE VISIT, bring the day of your appointment. Be sure we have your current insurance card, photo ID and valid referral (if required by your insurance) in advance of your appointment. Please arrive to the office or log into the virtual waiting room 5 minutes prior to your appointment.

Patient Registration Forms

The office generally runs on time.

We look forward to seeing you. This appointment is reserved for you, and while most patients are able to keep their appointments, we ask that if you must cancel or reschedule, you do so no less than 24 hours prior to your scheduled visit. In order to maintain a smooth patient flow and accommodate all patients, there is a $25 cancellation fee for virtual visits, $50 cancellation fee for medical visits and a $200 cancellation fee for cosmetic treatment visits automatically billed to patients who cancel/reschedule less than 24 hours in advance or fail to keep their appointment.

Patients without required referrals will be asked to reschedule or self pay for the visit.

Medical Records Release Form

Parental Consent for Treatment of a Minor

General Treatment Consent

You may also familiarize yourself with the  HIPAA Notice of Privacy Practices

Please see the Appointments page for more details.