• PATIENT WAIVER FOR NO REFERRAL

  • I acknowledge that I do not have a referral for my visit to Affiliated Troy Dermatologists and will be assuming full financial responsibility for today’s visit. If I receive any additional services from specialists, hospitals, laboratories, or other health care providers in connection with or as a result of this visit, those charges will also be my responsibility.

  •  /  /
    Pick a Date
  • Clear
  • Should be Empty: