Iowa City Dermatology

providing excellent dermatologic care for over 20 years

Iowa City Dermatology

Save time and complete patient forms prior to your appointment.  
 

Download forms 1 and 2 below, complete, and bring to your appointment.  For those who do not wish to do so, we will provide these forms during your visit.  If you are having difficulty downloading or printing the forms below, try opening the website with google chrome rather than internet explorer.  

If an appointment is made for a minor patient (under age 18), they must either be accompanied to their appointment by a parent / legal guardian, or they must arrive with a signed Consent Form for Preauthorization to Treat Minors and HIPAA Notice of Privacy Practices for Minor Patient which can be downloaded below. This signed consent can also be emailed/ faxed (319-339-3874) to the office prior to the appointment. 

**With the unpredictable and frequently changing nature of prescription coverage in recent years, it is helpful to be aware of your specific prescription coverage plan and, if possible, bring a copy of the prescription drug formulary for your plan to assist us in finding the lowest cost treatment option for your specific insurance plan**

1. Demographic information

2. Medical History

HIPAA Notice of Privacy Practices

HIPAA Notice of Privacy Practices for Minor patient

Release of healthcare information TO Iowa City Dermatology

Release of healthcare information FROM Iowa City Dermatology

Consent form for preauthorization to treat minors

 

269 N 1st Ave, Ste 100, Iowa City, IA, 52245                               319-339-3872                            Iowacityderm@gmail.com