Dermatology Partners, Inc. Logo
  • Home
  • About
    • Physicians
      • Ruth E. Tedaldi, M.D.
      • Rachel Herschenfeld, M.D
      • Carin Litani, M.D.
      • Hilary Haimes, M.D.
      • Morgan Murphrey, M.D.
      • Uchenna R. Okereke, M.D.
      • Lizanne Noble, N.P.
    • Aesthetic Staff
      • Gabriela Griffin, RN
      • Milena Turok
      • Luba Koroleva
      • Lambrini Kitsaki-Tsitsis
      • Amy Smith
    • Testimonials
  • Services
    • Medical
      • Skin Checks
      • Pediatric Dermatology
      • Adult Dermatology
      • Hair Loss
      • Photodynamic Therapy
    • Cosmetic
      • Neuromodulators
      • Hyaluronic Acid Fillers
      • Biostimulator Fillers
      • Laser Treatments
      • PRP (Platelet-Rich Plasma)
      • Sclerotherapy
      • Medium–Deep Chemical Peels
      • Laser Hair Removal
    • Surgical
      • Mohs Surgery
      • Skin Tags & Age Spots
      • Ear Repair & Ear Piercing
      • Excisions for Malignant & Benign Lesions
      • Acne Scarring Treatments & General Scar Revisions
    • Face & Body Contouring
      • Exilis Ultra®
      • EmSculpt® NEO
      • CoolSculpting®
      • AviClear®
    • Aesthetics
      • Medical Cleansing
      • Superficial & Medium Chemical Peels
      • Dermaplane & Dermapeel
      • Microneedling (SkinPen®)
      • Microneedling (VirtueRF)
      • PRX & PRX-C
      • PDRN (Mermaid / Salmon Sperm Facial)
      • KeraLase® with KeraFactor®
      • Vibraderm
      • Lutronic Ultra Laser
      • Hydrafacial®
      • Glo2 Facial
      • Skincare
  • Products
  • Media
  • FAQs
  • Specials
  • Gallery
  • Contact
    • Main Office
    • Dr. Tedaldi's Office
    • Aesthetic Suite
Book an Appointment
Patient Forms
phone icon
  • Home
  • About
    • Physicians
      • Ruth E. Tedaldi, M.D.
      • Rachel Herschenfeld, M.D
      • Carin Litani, M.D.
      • Hilary Haimes, M.D.
      • Morgan Murphrey, M.D.
      • Uchenna R. Okereke, M.D.
      • Lizanne Noble, N.P.
    • Aesthetic Staff
      • Gabriela Griffin, RN
      • Milena Turok
      • Luba Koroleva
      • Lambrini Kitsaki-Tsitsis
      • Amy Smith
    • Testimonials
  • Services
    • Medical
      • Skin Checks
      • Pediatric Dermatology
      • Adult Dermatology
      • Hair Loss
      • Photodynamic Therapy
    • Cosmetic
      • Neuromodulators
      • Hyaluronic Acid Fillers
      • Biostimulator Fillers
      • Laser Treatments
      • PRP (Platelet-Rich Plasma)
      • Sclerotherapy
      • Medium–Deep Chemical Peels
      • Laser Hair Removal
    • Surgical
      • Mohs Surgery
      • Skin Tags & Age Spots
      • Ear Repair & Ear Piercing
      • Excisions for Malignant & Benign Lesions
      • Acne Scarring Treatments & General Scar Revisions
    • Face & Body Contouring
      • Exilis Ultra®
      • EmSculpt® NEO
      • CoolSculpting®
      • AviClear®
    • Aesthetics
      • Medical Cleansing
      • Superficial & Medium Chemical Peels
      • Dermaplane & Dermapeel
      • Microneedling (SkinPen®)
      • Microneedling (VirtueRF)
      • PRX & PRX-C
      • PDRN (Mermaid / Salmon Sperm Facial)
      • KeraLase® with KeraFactor®
      • Vibraderm
      • Lutronic Ultra Laser
      • Hydrafacial®
      • Glo2 Facial
      • Skincare
  • Products
  • Media
  • FAQs
  • Specials
  • Gallery
  • Contact
    • Main Office
    • Dr. Tedaldi's Office
    • Aesthetic Suite
Book an Appointment
Patient Forms

Patient Forms

Check in Forms:

Medical Records

Medical records include, but are not limited to, a patient's medical history, test results, office visit notes, and operative reports related to treatments and medical services. The Medical Records Department can provide copies of your medical records related to your care at Dermatology Partners.


Please complete one of the following forms and email it to info@dermpartner.com. Please allow up to 14 days for processing.

Medical Records Request By Patient →

Medical Records Request By Practice →


Medical & General Patient Forms

Patient Information Sheet →

HIPAA Privacy Form →

Photo & Video Patient Consent Form →

Medical Clearance for Patients on Anti-Coagulants →


Laser Treatments

GentleLase Laser Hair Removal Consent →

Levulan® Blue Light Therapy →

Full CO₂ Laser Instructions →

Light/Moderate CO₂ Laser Post-Treatment Instructions →

Fraxel® Post-Treatment Instructions →

Surgical Procedures

Patient Consent for Minor Surgery →

Mohs Surgery Pre-Operative Forms →

Nail Procedure Consent →

Surgical Procedures for Excisional Procedure →


Cosmetic Injectables

Neuromodulator Consent Form (Botox®, Dysport®, Xeomin®, etc.) →

HA Filler Consent →

Injectable Filler Consent →

Sculptra Consent & Information Form →

Kybella Consent Form →

PRP Consent Form →


Wound Care Instructions

Sutured Wound Care Instructions →

Skin Graft Wound Care Instructions →

Ear Piercing Wound Care Instructions →

Main Office, Suite 480

Dr. Litani · Dr. Herschenfeld · Dr. Haimes · Dr. Murphrey · Dr. Okereke · NP Lizanne

65 Walnut Street
Suite 480
Wellesley, MA 02481

Monday – Friday: 8 AM - 5 PM

(781) 431-7733

Dr. Tedaldi, Suite 450

Dr. Tedaldi

65 Walnut Street
Suite 450
Wellesley, MA 02481

Monday – Friday: 8 AM - 5 PM

Vicki: (866) 923-5566
(781) 431-7733, Ext. 216

Aesthetic Suite

Gabriela · Milena · Luba · Lambrini 

65 Walnut Street
Suite 480
Wellesley, MA 02481

Monday – Friday: 8 AM - 5 PM

Saturday: 8 AM - Close (Lambrini Only)

(781) 431-0139

Cosmetic Appointments

(Main Office Only)

For all cosmetic treatments at our Main Office (Suite 480), please contact Ellen Blonder. Ellen coordinates cosmetic scheduling for the Main Office and serves as the direct assistant to Dr. Herschenfeld.


Please note: Cosmetic appointments for Dr. Tedaldi (Suite 450) are scheduled separately.

cosmeticcoordinator@dermpartner.com

Ellen Bonder: (781) 431-7733, Ext. 235
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