EMERGENCY CONTACT OR PARENT/LEGAL GUARDIAN (IF MINOR)
Please list the name(s) and Phone #(s) of the person(s) with whom you give us permission to discuss your medical condition as well as their relationship to you. If you are the parent or guardian of the patient, please include yourself in this list. (I.E. friend, neighbor, child, etc.)
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Thank you for choosing Cleaver Dermatology for your skin care specialty needs. We are committed to providing you with high quality and affordable healthcare. Because some of our patients have had questions regarding patient and insurance responsibility for services rendered, we have developed this payment policy. Please review, ask any questions you may have, and sign in the space provided. A copy will be placed in your patient file and will be provided to you upon request.
Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. Thank you for understanding our payment policy. Please let us know if you have any questions or concerns. I have read and understand the payment policy and agree to abide by its guidelines:
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Consent for Minor Surgery, Biopsy & Cryosurgery
PURPOSE
PROPOSED TREATMENT
OTHER ACKNOWLEDGEMENT DISCLOSURE
I am able to read and understand English. I understand that I will have the opportunity to discuss my procedure with the physician or other professional who is to perform the procedure and have all of my questions answered to my satisfaction.
PHOTOGRAPHIC CONSENT
I AUTHORIZED AND CONSENT TO THE TAKING OF A SERIES OF PHOTOGRAPHS OF THE SURGICAL AREAS FOR THE USE OF DR. CLEAVERFOR DOCUMENTATION OR EDUCATIONAL PURPOSES
Insurance and Privacy Policy Consent
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.