Name and Location of Pharmacy: Your prescriptions will be sent electronically to this location.
PRIMARY INSURANCE (please give your insurance card to the receptionist)
SECONDARY INSURANCE (please give your insurance card to the receptionist)
My signature below acknowledges that I understand the following:
Co-pays and deductibles will be collected at the time of service. I am responsible for timely payment of any balance.
Payment for cosmetic procedures and products are due at the time of service.
I authorize the medical providers to evaluate and treat my medical condition. I authorize the release of medical information as needed to my referring physician, consultants and insurance carrier to process insurance claims, applications and prescriptions. I also authorize payment of medical benefits to the physician.
There may be an additional charge from an outside laboratory for pathology services if a biopsy is performed.
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 Medical History
It is necessary to have this information in order to provide you with the highest quality medical care.