Parental/Guardian consent for treatment of a minor. (Must also send copy of parent/guardian Photo ID) 

Referral from PCP (Rarely required by insurance, but important if your insurance requires it. Otherwise you may be responsible for your bill if your insurance denies the claim due to lack of referral) 

Records Release Forms:

• As of November 1, 2016, all patients will be new patients.  Bravia Dermatology is a private practice.  Please visit braviaderm.com/Insurance to see which insurances we accept.
   
• If you saw Dr. Molenda while he was employed by ProMedica (November 2013-October 2016), please fill out a record request. (Click here for form)
   
• If you are transferring care from another dermatologist or if we need your records from another physician's office, please fill out a record release with the relevant information. (Click here for form)
   
• Click here for a BLANK record release form.