• 919.781.1050
  • 4225 Macon Pond Rd, Suite 300, Raleigh, NC 27607
  • 1110 SE Cary Pkwy, Suite 100, Cary, NC 27518

Patient Forms

Standard Forms

Patient Medical History

Notice of Privacy Practice 

Acknowledgement Receipt of Notice of Privacy Practice

Financial Policy

Financial Medicare Policy

Patient Registration Form (Under 65)

Medicare Registration Form

Authorization for Release of Information

Acknowledgement of Potential Cost 

All new patients must complete the above paperwork prior to appointment.

Medical Records Release Forms

Authorization to Release Medical Records

Authorization to Obtain Medical Records

Cosmetic Consult

Cosmetic Patient Consultation Form

Photo Release Form

Telehealth Forms

Telehealth Consent

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Raleigh

4225 Macon Pond Rd, Suite 300, Raleigh, NC 27607

Cary

1110 SE Cary Pkwy, Suite 100, Cary, NC 27518

Call Us

919.781.1050

Diagnosed with Hereditary balding or shedding, or noticing hair loss? ​

Blue Ridge Derm has partnered with

Eximia and you may qualify for the

local research study with compensation. ​

Please call to learn more at 919-800-5154​

Must be between 25-70 years old to participate. 

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