New Patient Paperwork
Please print and fill out all forms and bring them to the office with you at the time of your appointment.How did you find out about us?
New Patient Registration
Notice of Privacy Practices
Notice of Privacy Practices - Consent Form
Release of Medical Records
Consent Forms and Pre-Op Instructions
Please select the correct procedure link, print, and fill out all forms.
Email signed consents to firstname.lastname@example.org or fax to (985) 386-2698.
Consent for Photo and Video Utilization
Our practice often utilizes before and after photos or videos taken of medical and/or cosmetic procedures and treatments for internal and commercial uses. Please be aware that patients will not be compensated for the use of any image(s) for which they have given permission to Integrated Dermatology of Ponchatoula, LLC, doing business as Benson Dermatology, QnA Cosmetic Surgery, and QnA Medical Spa, (collectively, “Integrated”) to use for marketing purposes. Patient’s identities may be concealed by obstructing areas of the face and/or body.Photo/Video Consent Form