Patient Forms

Patient Resourses

New Patient / Registration Forms

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Our Office Policies


Equal Opportunity

Thank you for entrusting us with your health care. As we hope you are already discovering from our gracious setting and inviting, knowledgeable staff, all of us at Goodless Dermatology are sincerely committed to providing you excellent care. We value all of our patients and look forward to doing everything possible to ensure you have a wonderful experience.

Please read and initial all of the following policies. These office policies are designed to clearly communicate our services. Our office is exceptionally efficient and we strive to ensure that all of our patients have an equal opportunity to receive the best service possible.


HIPAA – Health Information Portability and Accountability Act

We protect your privacy in every way possible. Our office strictly adheres to the HIPAA law. All employees are fully trained on HIPAA guidelines and all of our office technology is carefully designed to provide maximum protection of your personal information. We never share your information with anyone not directly involved with your care, insurance or billing without your consent.

All patients must complete and sign our HIPAA policy form. All patients are also requested to present their photo ID at each visit. These are HIPAA requirements specifically designed to protect your identity from misuse. Please refer to our “Notice of Privacy Practices” posted in the lobby and on our website.


Cancellation Policy

We strive to provide exceptional medical care in a timely manner. Our staff understands your time is precious and that changes may occur with little notice. To efficiently serve all of our patients we require a 24-hour notice for all cancellations. This provides us enough time to offer your valuable appointment time to another patient. Late arrivals may be asked to reschedule.

Appointments cancelled with less than 24-hours notice may be charged a cancellation fee.

As a courtesy to you, the first no-show fee may be waived based on circumstances. It is our strong desire to create a lasting relationship built on mutual respect. We do everything we can to accommodate your schedule and we thank you in advance for your cooperation.



All minors must be accompanied by a parent or legal guardian on their first visit. After the first visit, a waiver can be signed to allow us to continue active treatment for the minor without the parent/legal guardian present at future visits. If you are interested, please ask our staff for more information.


Prescription Refills

Please allow us up to two days to process your refill request. Most refills are generally completed within one business day. To maintain the highest clinical standards, we require at least an annual exam for prescription refills. Your provider may require more frequent visits depending upon the medical condition.

The fastest way to obtain your refill is for your pharmacist to directly fax/email the request.

Prescription refills are a routine procedure and we gladly perform them during normal business hours. Any refill requests made after-hours (ie. on the emergency line) may incur an additional fee.


Financial Policy

We adhere to a clear and comprehensive financial policy. As a courtesy to all of our patients, it is our normal practice to:

For All Patients


Option 1 – Medicare

My initial here and full signature below indicates that I hereby:


Option 2 – Commercial Insurances (ie. HMO, PPO, HSA)

Goodless Dermatology will release all information necessary to process my claims to my insurance company and its agents


Option 3 – Self-Pay Policy

Dr. Goodless extends a 10% discount on all services typically covered by commercial insurance as a courtesy to all of her self-pay patients. Goodless Dermatology Self-Pay Policy requires self-pay patients to pay $100 upon check-in.

At the end of the visit:

Self-pay patients may be eligible for discounted rates with local pathology laboratories.