Patient Intake & Medical History Form
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  • English (US)
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  • New Patient Health Assessment

    Luna Dermatology
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How Did You First Learn About Luna Dermatology?*

  • Page 2 of 6: Insurance Information

  • Policy Holder Date of Birth
     - -

  • Page 3 of 6: Patient Medical History

  • Are you currently taking any medications or supplements?*
  • Are you allergic to any medications or foods?*
  • Have you ever had skin cancer?*
  • Have any of your relatives had skin cancer?*
  • Do you have a history of any other skin conditions?*
  • Do you have a history of, or currently have, any of the following? (Please check all that apply)
  • Have you had other types of cancer?
  • Have you had any prior surgeries?
  • Social History: Please Check all that apply - Cigarette smoking*
  • Social History: Please Check all that apply - Alcohol use*
  • Today's Date*
     - -

  • Page 4 of 6: Cosmetic Questionnaire

    We are proud to offer the latest non-invasive skin care treatments. Dr. Bair and her team are highly experienced in performing the latest in cosmetic procedures. We encourage you to discuss any of your skincare goals with our team.
  • Are you interested in learning more about our treatments for any of the following? (please check all that apply)*
  • Are you interested in a free consultation with our Aesthetician? Our aesthetician can customize skincare services such as facials, extractions, peels, and microneedling.
  • Are you interested in learning about skincare products that may work well for your skin?

  • Page 5 of 6: HIPAA Privacy Information

  • Preferred Method of Contact (choose all that apply)*
  • May we leave a message on your answering machine / voicemail box with private information?*
  • May we contact you via email with lab results and treatment information pertaining to your health?*

  • If you would like, you may authorize a trusted individual to receive healthcare information on your behalf. If you would like to do so, please fill in the following blanks below.

    I authorize Luna Dermatology to discuss my personal health information, including appointment details, treatment data, and lab results with the following individual: , who is my . Their contact number is:       .

  • Medical Photography Permission

  • Clinical photographs are taken to help our medical team better assess your treatment needs, to track results, and to tailor our approach over time from one visit to the next. They provide a good visual history and reference for both patients and dermatology providers alike. They remain in your chart and are not divulged to another party without your explicit permission. While they are helpful, your refusal will not affect your ability to obtain treatment.*

  • Audio Scribing Tool

  • I acknowledge that my healthcare provider may use advanced software during my visit to assist with medical documentation by temporarily recording the visit and generating notes to enhance accuracy and patient care. I understand that these recordings are done in a privacy-compliant manner, and are not retained beyond their necessary use for documentation purposes. By signing below, I consent to the use of this technology as part of my services.

  • Patient Date of Birth*
     - -
  • Legal Guardian Date of Birth (if applicable)
     - -

  • Page 6 of 6: Patient Financial Responsibility Agreement

    Thank you for choosing Luna Dermatology. Your understanding of our financial responsibility policy is an essential element of your care. Please read the policy and sign below. If you have any questions, please discuss them with our team.

  •  Payment:

    • Payment for services, including co-payments, are due in full at the time of service. Prior balances must be paid in full prior to being seen at your next appointment.
    • According to your insurance plan, you are responsible for all co-payments, deductibles, and coinsurances.
    • We accept cash, checks, credit / debit cards, and CareCredit financing. We are happy to accept HSA/FSA/Flex Spend Programs for all medical related expenses. Please note that we cannot accept HSA/FSA/Flex Spend Programs for any cosmetic or non-medically necessary services.
    • Patient balances are billed on receipt of your insurance plan’s explanation of benefits. Your remittance is due within 15 business days of your receipt of your bill. Prior balances must be paid in full before scheduling any appointments.
    • If we do not participate in your insurance plan, or you are a self-pay patient, payment in full is expected from you at the time of your visit. We will supply you with an invoice that you can submit to your insurance for reimbursement. 

    Insurance Plans:

    • It is your responsibility to keep us updated with your correct insurance information. If the insurance you designate is incorrect, you will be responsible for payment of the visit and submission to the correct plan for reimbursement.
    • It is your responsibility to understand your benefit plan regarding in-network providers, covered services, and participating laboratories. Every insurance By signing below, you agree to accept full financial responsibility as a Patient who is receiving medical services, or as the Responsible Party. Your signature verifies that you have read this Patient Financial Responsibility statement, understand your responsibilities, and agree to these terms. A digital copy of this document shall be as effective and valid as the original.

    Laboratory/Pathology Charges:

    • Depending on your insurance carrier, you may be required to pay a separate co-payment for any specimen taken during your visit. For example, biopsies need to be sent to a third-party laboratory for pathology reading and diagnostic testing. The charges for lab testing may be your responsibility or may be covered by insurance, and we encourage all patients to familiarize themselves with their coverage as we do not have control over that process. 

    Cosmetic Services:

    • We provide both medical and cosmetic dermatologic services. Please note that these services are billed separately, even if you are seen for both medical and cosmetic reasons during the same appointment. 
    • The removal of most benign growths is considered cosmetic and is not covered by insurance. The office visit consultation to determine if a growth is benign is billed to insurance. 

    Referrals:

    • It is your responsibility to know if a written referral or authorization is required to see specialists, whether preauthorization is required prior to a procedure, and what services are covered. If your insurance has designated a primary care physician (PCP), you are required to have prior authorization from your PCP prior to your office visit with us. If authorization is not provided, you will be asked to reschedule or pay for the visit at the time of service.

    Missed Appointments and Late Cancellations:

    • When patients fail to show for their appointment, or cancel last minute, it disrupts the schedule and creates a burden on other patients.  As such, the following fees will apply if you do not show up for your appointment or fail to notify us of a need to change / cancel your appointment with at least 24-hours advanced notice. 
      • General Medical Visit: $50
      • Cosmetic Consultation: $50
      • Cosmetic Appointment: $100
      • Surgical Appointment: $100 
    • Missed appointment / late cancellation fees will be charged via the credit card on file and we will email a receipt. No future appointments can be scheduled until the fees are paid. 

    Non-Payment on Account:

    • Past due accounts may be subject to collection proceedings. The Patient or the Patient’s Responsible Party understands that Practice has the right to disclose to an outside collection agency all relevant personal and account information necessary to collect payment for services rendered.  We reserve the right to refuse to see any patient that has been placed into collections.

    Aesthetic Packages / Product Return Policy: 

    • We offer returns on most unused products within 30 days of purchase. Products that are not well-tolerated by the patient or have defective packaging can be returned to the office within 30 days of purchase for a refund or exchange. Due to state laws, prescription products are not refundable.
    • Unless otherwise agreed to in writing, all packages for aesthetic services such as microneedling, PRP, and others, expire six months after purchase.

    Authorization for Release of Information and Payment:

    • I authorize the release of any medical information requested by my insurance carrier for administration of claims and services, and the release of information back to my physician. I also authorize payment of medical benefits, including Medicare benefits, to BB Medical and Dermatology Inc (DBA Luna Dermatology) for services rendered. If my medical insurance does not pay for services rendered, I agree to pay Luna Dermatology for these services. If the patient is a minor, I acknowledge that the parent or legal guardian is responsible for payment of services.

    Credit Card on File Authorization:

    • In support of our efforts to promote seamless checkout, contactless billing, and our overall green initiative to reduce mailing materials, Luna Dermatology encourages patients to keep a credit card on file. This information is encrypted and stored securely. The card on file will be charged 30 days after a billing statement has been sent to your address.
    • Providing a credit card on file is optional and not required to receive services. If you choose to opt out, alternative billing arrangements will be provided.

    By signing below, you agree to accept full financial responsibility as a Patient who is receiving medical services, or as the Responsible Party. Your signature verifies that you have read this Patient Financial Responsibility statement, understand your responsibilities, and agree to these terms. A digital copy of this document shall be as effective and valid as the original.

  • I authorize Luna Dermatology to charge the credit card on file automatically for payments owed to my account (or for the patient noted at the bottom of this form) for services rendered. I agree to update any information regarding this account to keep it current. I authorize Luna Dermatology to charge my card in full for any outstanding balances.*
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