New Patient Form

Lakeside Dermatology

Please correct the errors described below.

PATIENT INFORMATION

Pharmacy Information

(This will be the pharmacy where all of your prescriptions will be sent)

Insurance Information

(Please Give Insurance Cards and Photo ID to Receptionist to Copy)

Primary Insurance

Secondary Insurance

Referral Information, Patient Financial Policy and Signature on File

How Did You Hear About Us?

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 Lakeside Dermatology’s Notice of Uses and Disclosures of Protected Medical Information (Notice of Privacy Practices).

DISCLAIMER: By signing your name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Payment Policy

Self-Pay Patients - I understand that I am required to pay 100% of the total bill at the time of service.

Insured Patients - I understand that I will be responsible for paying my deductible, co-payment, co-insurance, and charges for any non-covered and/or cosmetic services.

Laboratory Services-I understand that if I have a skin biopsy and/or any other laboratory services performed, it will be sent to an outside laboratory to be tested and I may receive a bill from the laboratory. (For example: Ameripath, Quest, LabCorp, etc.)

DISCLAIMER: By signing your name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

PATIENT MEDICAL HISTORY

Past Medical History

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Past Surgical History

Skin Disease History

Medications

Please list all current prescription and/or OTC medications

Add Another Medication

Allergies

Social History

Family Medical History

Assignment and Release

I hereby authorize payment directly to Michael J. Rogers, M.D. for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents. I authorize the above doctor and/or any provider or supplier of services in Lakeside Dermatology to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions

DISCLAIMER: By signing your name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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