REGISTRATION FORM

Fort Bend Skin Cancer Center

281.980.6647

Patient Information

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Is someone other then you financially responsible for your medical care?

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Insurance Information

Does or will the receptionist have a copy of your insurance card(s)?

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Primary Care Physician

Do you have a primary care physician (Family Physician, Internist, or OB/GYN)?

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Would you like us to send a copy of our findings and treatment outcome to this physician?

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Consent to Treatment

I voluntarily consent to receive medical and health care services that may include diagnostic procedures examinations and treatment.

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Financial Responsibility and Assignment of Benefits

The undersigned hereby authorizes the release of any information relating to all claims for benefits submitted on behalf of myself and/or dependents. I further expressly agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim to be submitted for myself and/or dependents. I will be bound by this signature as though I had personally signed the particular claim. I acknowledge and understand that I am responsible for all of the charges for the services rendered to me or any member of my family. The information above is complete and accurate to the best of my knowledge.

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Signature of Patient or Other Legally Authorized Person

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Keith E. Schulze, M.D.

Dr. Keith Schulze, a fellowship trained member of the American College of Mohs Surgery, opened the Fort Bend Skin Cancer Center in February 2007 after practicing in the Texas Medical Center for six years. His practice is dedicated to the treatment of skin cancer, reconstructive surgery after skin cancer removal, and the surgical treatment of benign skin lesions. Mohs micrographic surgery is a highly specialized treatment for skin cancer that offers the highest potential for cure while minimizing the cosmetic impact; even if previous treatments have failed. With advanced fellowship training as a Mohs surgeon, Dr. Schulze can provide both the thorough diagnosis and effective treatment you need to address your condition.