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Welcome to Bergen Dermatology Specialists

We look forward to seeing you for your visit.

Please fill out the electronic form below.
If you don’t want to fill out this form electronically, click here to print a PDF version and fill it out prior to your appointment.
Thank you.

    • 1.
      Patient Registration
    • 2.
      HIPAA Acknowledgement
    • 3.
      Covid Acknowledgement
    • 4.




    SEASONAL (Optional)

    PERSONAL CONTACT INFORMATION (Select "NO" if you would not like a detailed communication 'i.e. lab results' to be left for all below contacts.)

    EMERGENCY CONTACT INFORMATION (Select "NO" if you would not like a detailed communication 'i.e. lab results' to be left for below contact.)



    PARENT/GUARDIAN OF MINOR (if applicable)




    (SELF PAY patients, please select 'NO')

    (All patients must provide a copy of their insurance card at the time of their visit)



    Health History

    Note: Numerous concerns or complex issues may necessitate multiple visits.

    Past Medical History (Select ones that apply)



    Hearing loss


    Cold Sores



    Myasthenia Gravis


    Coronary Artery Disease

    Atrial Fibrillation

    Heart Attack




    Kidney Disease


    Hay Fever

    Chronic Obstructive Pulmonary Disease

    Pulmonary Embolism / Blood Clots

    Ulcerative Colitis / Crohn's Disease

    GERD (Heartburn)


    Leukemia / Lymphoma

    HIV / AIDS


    Radiation Treatment (if yes, what location)

    Arthritis (if yes, what type)

    Hepatitis (if yes, what type)

    Cancer (if yes, what type)

    Other (specify):

    Past Surgical History (Select ones that apply)



    Artificial Heart Valve

    Mitral valve prolapse

    Pre-op/ dental antibiotics

    Heart Stent Placement (Angioplasty)

    Hip replacement (if yes, enter details)

    Knee replacement (if yes, enter details)

    Organ Removal (if yes, which one)

    Organ Transplant (if yes, which one)

    Other (specify):

    REVIEW OF SYSTEMS (Do you currently have the following symptoms?)




    Unintentional weight loss

    Nausea / Vomiting



    Abdominal Pain

    Easy bruising

    Blood clots

    Swollen lymph nodes

    Are you currently breastfeeding?

    Joint pain

    Rash / Itch




    Eye Irritation

    Shortness of breath

    New loss of smell or taste

    Sore Throat

    New onset of cough

    Do you have COVID-19

    Have you been in contact with someone with COVID-19

    Are you currently pregnant? (if yes, enter details)

    Other (specify):

    Skin Disease History (Select ones that apply)


    Actinic Keratoses

    Basal Cell Skin Cancer

    Blistering Sunburns


    Flaking or Itchy Scalp

    Hay Fever/Allergies

    Precancerous Moles


    Squamous Cell Skin Cancer

    Keloid Scars

    Other (specify):

    Family History of Melanoma (if yes, enter details)

    Melanoma (if yes, enter details)







    Codeine or other narcotics

    Other (specify):

    Antibiotics (if yes, which antibiotic)

    Social History

    Cigarette Smoking


    Tanning Bed Use

    Received a pneumonia vaccination?

    (Only for patients 65 years and older)

    Office Policies


    Payment is required for all services. If you have insurance, your payment is based on your negotiated contracted rates with your insurance company. You are responsible to verify with your insurance company, that the provider you are seeing is in-network with your insurance policy. You are responsible for any copays, deductibles, coinsurance, out of network balances, any non-covered services, and usual and customary amounts for non-contracted insurance. Co payments and unpaid balances will be collected at the time of service at check-in. If you are unsure of your copay, deductible, or coinsurance amount, please contact your insurance company for clarification prior to your appointment. I understand that in the event that services are not covered or out of network under my insurance, I accept full financial responsibility for all non-covered services. For patients without insurance, $200.00 will be collected during check- in and the remaining balance based on the services provided will be collected at checkout. For cosmetic visits, a $150.00 cosmetic consultation fee will be charged when the appointment is made, this will be applied to the cosmetic service fee if a procedure is completed within 3 months. The remaining fee for the cosmetic service will be collected at checkout on the day of the procedure. Cosmetic fees are non refundable. You will be sent a statement to the physical address or email address you have on file. You will be responsible to contact the office if you have a change in either address. Once the final statement is sent, your account may be sent to our legal collection agency. I acknowledge that I shall be responsible for the collection agency fee or the actual collection cost to the practice. At this point, all contact regarding your account must then be made with the legal collection agency’s account representative. If you need to set up a payment plan, please call the office prior to your visit. I further acknowledge that there is a $25.00 banking fee for all returned checks.


    If a referral is required by my health insurance plan, I understand that it is my responsibility to obtain the referral from my primary care provider and assure that it is available at the time of my visit. I further understand that it is my responsibility to keep track of the number of visits I have used, the expiration date, and obtain a new referral as needed. I understand that should I fail to have a valid referral at the time of my visit, I will need to pay the cancellation fee and reschedule.


    Should you be unable to keep the appointment, please cancel at least 24 hours prior to the appointment time. Cancellations must be on a business day, (i.e. Monday appointments need to be cancelled on Friday). Otherwise, there is a cancellation fee of $50 for general dermatology appointments & $100 for surgical and cosmetic dermatology appointments.


    All patients new and returning are required to present their current insurance card(s) at every visit. I understand by signing below that I am responsible for notifying the office of any changes to my insurance or contact information.

    Notice of Privacy Practices Summary & Receipt of Written Acknowledgement Form

    This summary of our privacy practices contains a condensed version of our Notice of Privacy Practices.

    Our full length notice is available upon request. PLEASE REVIEW IT CAREFULLY. Effective Date: Today

    This notice describes how medical information about you may be used and disclosed & how you may gain access to this information. We understand that your medical information is personal to you, and we are committed to protecting your information. As our patient, we create medical records about your health, our care for you, and the services and/or items we provide to you as our patient. By law, we are required to make sure that your Protected Health Information is kept private.

    How will we use or disclose your information? Here are a few examples:

    • For Medical treatment
    • To obtain payment for our services
    • In emergency situations
    • For appointment & patient recall reminders
    • To run our Practice more efficiently & ensure all our patients receive quality care
    • To avert a serious threat to health or safety
    • For organ and tissue donation
    • For workers' compensation programs
    • In response to certain requests arising out of lawsuits or other disputes

    If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact our office manager. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

    You have certain rights regarding the information we maintain about you. These rights include:

    • The right to inspect and copy
    • The right to amend
    • The right to an accounting of disclosures
    • The right to request restrictions
    • The right to a paper copy of this notice
    • The right to request confidential communications


    I am a parent/legal guardian of   


    I wish to be seen for a dermatologic issue(s). I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, federal and state health agencies recommend social distancing. I recognize that the doctors and staff at Bergen Dermatology Specialists are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is inherent risk of becoming infected with COVID-19 by virtue of being seen in Bergen Dermatology Specialists offices. I hereby acknowledge and assume this risk, and I give my express permission for Bergen Dermatology Specialists doctors and staff to proceed with my upcoming visit(s).

    I understand that, even if I have been tested for COVID and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test. I understand that possible exposure to COVID-19 before/during/after my upcoming visit(s) may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications, and the risk of death.

    I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my upcoming visit(s).


    I am a parent/legal guardian of   

    When you submit, your form will be sent to a HIPAA secure account.