Patient Information Form

Please correct the errors described below.

THIS SECTION MUST BE COMPLETED FOR ALL PATIENTS:

MAILING ADDRESS:

PARENT, SPOUSE, OR RESPONSIBLE PARTY (if different from patient)

INSURANCE COVERAGE

EMERGENCY CONTACT INFORMATION:

If yes, please provide their names and phone numbers below.

RECEIPT OF NOTICE OF PRIVACY PRACTICES:

My signature below indicates that I have received and/or reviewed a copy of my physician's Notice of Uses and Disclosures of Protected Medical Information (Notice of Privacy Practices). I have been given the option of signing a separate Patient Consent Form.

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.

PAYMENT POLICY:

You will be responsible for paying your annual deductible, copayment and charges for any non-covered medical and cosmetic services at the time of service.

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.

DERMATOLOGY MEDICAL HISTORY

Women

Completed by:

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.

werwer

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