NP form - patient info - outline copy 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name and date of birth in the designated fields at the top of the form.
3. Review each policy listed carefully. Initial next to each policy to indicate your understanding and acceptance.
4. For the Release of Medical Information section, indicate whether you authorize Westlake Dermatology to release your medical information to your spouse, parent, or guardian by checking the appropriate box.
5. If you authorize release to your primary care physician, provide their name and phone number in the specified fields.
6. In the Contact Permission section, select 'Yes' or 'No' for leaving messages on an answering machine and for speaking with authorized entities. Fill in their names and relationships as needed.
7. Complete the Unaccompanied Minors section if applicable, ensuring consent is noted for treatment.
8. Finally, sign and date the acknowledgment at the bottom of the form to confirm that you have read and accepted all policies.

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