Patient Consents

These forms are available to you in our patient portal, and also here for easy access. If you have questions please call us at (203) 635-0770. Completed forms can be emailed to info@moderndermct.com, please include your full name and DOB in the email when sending.

Click on the name of the form you need:

• Notice of Privacy Practices

• HIPAA Authorization + Consent

• Insurance Signature on File

• Telehealth Consent

• Confidential Communication Request

• Patient Portal Instructions

• Financial/Office Policies / En Espanol

• Patient Photogenic Consent Form

Consent for Minor: Parent or Guardian must accompany children under age 18 to their first appointment at our practice. If your child will be attending future appointments alone, or be accompanied by a caregiver other than their primary guardian (e.g. babysitter) please complete this form and send it to info@moderndermct.com before his/her appointment.