Demographics & Consent Form

Welcome to Our Office

Today’s Date

Patient Last Name

Patient First Name

Middle Initial

Preferred Name

Date of Birth

Social Security #

Sex

M F

Previous Name

Mailing Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

Employer

Occupation

Please initial here if you authorize Lower Highlands Dermatology to contact you via e-mail and/or text message.

How did you hear about our office?

Primary Care Physician

Phone

Preferred Pharmacy

Phone or Major Crossroads & City

Emergency Contact Name

Phone

Insurance: Provide your insurance card(s) at check-in.

Primary Insurance

ID/Policy #

Claims Address

Group #

City, State, Zip

Phone

Secondary Insurance

Phone

Please select your relationship to the primary insurance holder

Self Spouse Child

Other (Please Specify)

If other than Self, Policy Holder Name

Date of Birth

Responsible Party (if patient is under 18):

Name

Date of Birth

Social Security #

Mailing Address (if different from above)

City

State

Zip

Home Phone

Employer

Work Phone

Practice Consents

Consent for Treatment

You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks involved. This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended and consent to treatment at this office. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions. I voluntarily request a physician and/or other designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

Consent for Test Result Notifications

I give Lower Highlands Dermatology permission to leave all lab results, test results, and other medical information and advice on:(check all that apply)

Voicemail on Cell

Message at Home

E-mail (Biopsies Only)

Do not Leave a message

Other

Notice of Privacy Practices

I acknowledge that I have reviewed the Lower Highlands Dermatology Notice of Privacy Practices and that a copy is available at the reception desk as well as www.lohiderm.com as required by law.

Printed Name/Signature:

Date:

Relationship to patient

Self Parent Guarantor

Thank you for choosing Lower Highlands Dermatology for your skincare needs.

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