Cosmetic Demographic Form

Patient Information

Patient's Last Name:

First Name

M.I.

Sex

M F

Title

Mr. Mrs. Dr. Ms. Miss

Street Address

City

State

ZIP Code

Home Phone No.

Employer Phone No.

Cell Phone No

Preferred Phone Number (Select One)

Home Work Cell Other

If other, please specify.

Marital Status (Select One)

Single Married Divorced Separated Widowed Other

Date of Birth

Social Security

Email address

Employer

INSURANCE INFORMATION

PRIMARY INSURANCE

SUBSCRIBER'S NAME

Grp No.:

Policy No.:

Copayment:

Address of Subscriber: (If different than above)

Enter Number:

Subscriber's Date of Birth:

Subscriber's Social Security No:

Employer:

ADD SECONDARY INSURANCE

ADD TERTIARY INSURANCE

REFERRING AND RESPONSIBLE PARTY INFORMATION

Referred By: (please select appropriate box)

Friend/Relative Google Ad Healthgrades Internet Ad Websites Other

If other, please specify.

Referring Provider:

PCP Name (If different than your referring provider):

Legally the responsible party is the person signing the financial agreement and/or the patient. Regarding patients up to the age of 26: We are aware there are reasons patients wish to have financial statements sent to an additional person(s). If you want the statement sent to someone other than the patient/responsible party, please list the name, address, DOB, and relationship to the patient below. The practice reserves the right to default to the primary subscriber.

Name:

Relationship to the patient:

DOB:

Address:

Phone Number:

IN CASE OF EMERGENCY AND ACKNOWLEDGEMENT

Name of Spouse/Relative/Friend:

Relationship to Patient:

Please input Selected Number:

By signing below, I authorize cosmetic treatment/service from the Skin Cancer & Dermatology Center and their delegated medical professional and/or provider. I recognize that outcomes are not a guarantee and may vary. I understand that individual expectations for the desired effect are subjective, and I may be disappointed with the results. I acknowledge additional treatments/services may be necessary to achieve the preferred outcomes. You may receive promotionals information regarding product and service specials.

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.

Patient/Guardian Signature

Printed Name

Date

Your information will be encrypted.