San Diego Family Dermatology

Name of Patient

First NameLast Name

Sex Assigned at Birth

Date of Birth of Patient

Date

Home Phone Number

Area CodePhone Number

Mobile Phone Number

I authorize SDFD to contact me by SMS text message & voice correspondence via our electronic health record system, Practice Fusion. I understand I will receive text messages and voice correspondence with appointment reminders and other needed information. I further understand that message/data rates may apply to messages sent through SDFD to my cell phone if my cell phone plan does not include unlimited texting/data. I may opt-out of receiving text communication at any time by calling SDFD at 619-267-8303 or 619-579-5115, or by emailing (not encrypted): info@sdfamilyderm.com

I authorize SMS/text messages

Email

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance

Other Insurance

Insurance ID #

Insurance Group #

Has the patient been to either of our offices before?

Does the Patient have an existing appointment that needs to be cancelled or rescheduled?

How should we contact you?

Best Day (s) for an Appointment

Best Time of Day

What location(s) do you prefer for your appointment?

Do you Prefer a Female of Male Physician?

If you prefer a specific doctor, please indicate their name here.

If you were previously a patient at Skin Surgery Medical Group in Clairemont please indicate who your provider was?

What type of appointment would you like (We prefer all new patients to be seen in office. If that is not possible, please email us)?

Additional Info

APPOINTMENT REQUEST FORM