Patient Registration Form

Welcome to Dermatology Associates Online Patient Registration System! Registering online with us is convenient and secure.

Your confidential information will be transferred securely over SSL (Secure Socket Layers) with 256 bit encryption. The lock in your browser indicates that your registration process is safe and secure.

Step 1 - Patient Registration Information

Indicates a required field.

Patient Information

* Last Name:

* First Name:

Middle Initial:

* Choose the office location for your appointment:

* Marital Status:

Single

Married

Divorced

Widowed

* Date of Birth:

* Patient Sex:

Male

Female

Language:

Decline to answer language

Ethnicity:

Decline to answer ethnicity

Race:

Decline to answer race

Emergency Contact Information

* Name:

* Relationship to Patient:

* Phone:

Patient Contact Information

* Primary Phone:

Work Phone:

Mobile Phone:

Patient Email Address:

* Address:

* City:

* State:

* Zip:

Guarantor Information (To Whom Statements are Sent)

Is Guarantor Information Same as Patient?

* Last Name:

* First Name:

* Address:

* City:

* State:

* Zip:

* Phone:

Guarantor Employer:

Guarantor Employer Phone:

* Date of Birth:

Confidential Communications

I authorize Dermatology Associates to share my health information with the individuals listed below. This authorization will remain in effect for one year unless I notify Dermatology Associates otherwise. Please Note: We encourage you to list all members of your household who you trust to give/receive medical information including pathology reports, appointment information or billing information, etc.

Persons Authorized

Name:

Date of Birth:

Relationship:

+ Add a Person

Name:

Date of Birth:

Relationship:

+ Add a Person

Name:

Date of Birth:

Relationship:

Who is your medical (family) doctor?:

Did a Physician Refer you to Our Practice?:

Yes No

Name of Referring Physician:

How did you hear about us?:

* Do you have Insurance?

Yes

No ('No' Hides insurance information form fields below)

* Past Surgical History

* Please check all that apply ( If none of the choices below apply to you, check the 'NONE' box):

* Skin Disease History

* Please check all that apply. If none of the choices below apply to you, check the 'NONE' box.

Sun Exposure

* Do you wear Sunscreen:

Yes

If yes, what SPF?:

* Do you tan in a tanning salon?:

Yes

Melanoma

* Do you have a family history of Melanoma?:

Yes

If yes, which relative(s)?:

Social History:

Please check all that apply:

Cigarette Smoking:

Currently Smokes

Has smoked in the past

Never smoked

Former Smoker

Alcohol Use:

EtOH- None

EtOH- less than 1 drink per day

EtOH-1-2 drinks per day

EtOH-3 or more drinks per day

Skin Cancer Family History (Only first degree relatives)

Preferred Pharmacy Information:

Pharmacy Name:

Pharmacy Phone:

Pharmacy City or Zipcode:

Please check all that apply:

* Pregnancy

* Are you pregnant or currently trying to get pregnant?:

Yes

Assignment and Release:

I hereby authorize my insurance benefits to be paid directly to the physician.
I understand that I am financially responsible for all non-covered services and any covered services not paid by my insurance within 90 days.
I authorize the physician to release any information required to process insurance claims.
For self-pay patients - I understand that I must pay a fee of $100.00 at the time of check in. I understand that I will be responsible for any additional charges related to the services provided for me at my visit.
I agree to pay any co-payments and/or balances on previous visits at check-in. I understand Payment arrangements can be made on large balances. Cash, checks, and major credit cards (except American Express) are accepted. $25 charge for returned checks. Any patient credit of $10 or less will be applied to future dates of service unless I request a refund.
It is my responsibility to obtain any referrals required by my insurance carrier.
I understand that cellphone use and/or audio/video taping is prohibited in clinical areas.
I give permission to DA to leave messages on my voicemail and/or to send texts to my mobile number. (Messages may be from our staff or automated)
I understand that specimens obtained during my visit may be sent to a pathologist for interpretation.
If I am late for my appointment, I understand DA cannot guarantee that I will still be able to see a provider.
I understand I am to provide notice of cancellation no less than 24 hours in advance for clinical appointments and no less than 72 hours for surgical appointments. Dermatology Associates reserves the right to charge a no-show or cancellation fee of $50 for more than two no-shows or day of cancellations within any 24-month period.
I have received and understand the Notice of Privacy Practices.
I have received and understand the Patient Financial Responsibility Policy.

Cancellation Policy

Dermatology Associates respectfully requests patients provide notice of cancellation for any clinic appointments no less than 24 hours in advance and no less than 72 hours for any surgical appointments. Dermatology Associates reserves the right to charge a no-show or cancellation fee, outside of these guidelines, of $50 for more than two no-shows or cancellations within 24 hours within any 24-month period.

Click here to agree to our terms

* Your Email Address:

* Signed:

* Date: