The Medical Quarters
5555 Peachtree Dunwoody Rd. NE, Suite 190
Atlanta, GA 30342
Phone: (404) 256-4457 Toll-Free: (800) 233-0706
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Patient Forms

New Patient Registration and Health Information Forms

*Please note that all forms are now managed through our patient portal. Please log into the DAA patient portal to complete any necessary forms.*

 

Please download and print these two pdfs: New Patient History Form, and Patient Registration Form. Fill out your information, and bring these with you when you come into our office. Thank you!

Please click here to view our HIPAA policy regarding the privacy and dissemination of patient information as of 2/24/2010.

 

Authorization for Use/Release of Health Information Form

 

Please download and print this pdf: Authorization for Use/Release of Health Information. Fill out the information and bring it with you when you come into our office. Thank you!

 

The Surgical Suite Forms

 

Please download and print these three pdfs before visiting The Surgical Suite: The Surgical Suite Patient Notification, Notice of Privacy Practices, and The Surgical Suite Privacy Practices Notices Acknowledgement. Fill out your information, and bring these with you when you come into our office. Thank you!

 

Patient Post-Experience Survey

 

Please download and print this pdf: Patient Post-Experience Survey.  Fill out the information, and fax to us at 404-843-3469 or or you may complete it and e-mail it directly to us online to sharondaa@dermatlanta.com.

Thank you!