New Patient Registration Form

New Patient Registration Form
Name*

First NameMiddle NameLast Name
Reason for appointment (simple)*
Initial esthetician/laser evaluation ONLY (leave unchecked if desiring physician medical appointment for evaluation)

Yes
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age*
Email*
example@example.com
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Social Security Number*
Gender

MaleFemale

Insurance Information
** If secondary or tertiary insurance does not apply to you, then you may leave those blank.
Primary Insurance Policy Holder's Name (if different from patient or responsible party)
Patient’s Relationship to Policy Holder
Primary Insurance Policy Holder’s Date of Birth

MonthDayYear
Date
Primary Insurance Policy Holder’s SS #
Primary Insurance Company Name*
Primary Insurance Policy Number*
Primary Insurance Group Number*
Secondary Insurance Policy Holder's Name (if different from patient or responsible party)
Patient’s Relationship to Policy Holder
Secondary Insurance Policy Holder’s Date of Birth

MonthDayYear
Date
Secondary Insurance Policy Holder’s SS #
Secondary Insurance Company Name
Secondary Insurance Policy Number
Secondary Insurance Group Number
Tertiary Insurance Policy Holder's Name (if different from patient or responsible party)
Patient’s Relationship to Policy Holder
Tertiary Insurance Policy Holder’s Date of Birth

MonthDayYear
Date
Tertiary Insurance Policy Holder’s SS #
Tertiary Insurance Company Name
Tertiary Insurance Policy Number
Tertiary Insurance Group Number

If patient is a minor please enter responsible party information. (Note: We do not bill absent parents, the adult presenting the minor for care is the responsible party.)
Responsible Party's Name

First NameLast NameSuffix
Responsible Party's SS #
Responsible Party's Date of Birth

MonthDayYear
Date
Responsible Party's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Responsible Party's Home Phone
Please enter a valid phone number.
Responsible Party's Work Phone
Please enter a valid phone number.
Responsible Party's Cell Phone
Please enter a valid phone number.

Optional Credit Card Information

CREDIT CARD AUTHORIZATION
Optional, Non-required Convenience

If you have ever checked into a hotel or rented a car, the first thing you are asked for is a credit card, which is imprinted and later used to pay your bill. This is an advantage for both you and the hotel or rental company, since it makes checkout easier, faster, and more efficient. We have implemented a similar policy. You will be asked for a credit card number at the time you check in and the information will be held securely until your insurances have paid their portion and notified us of the amount of your share. At that time, any remaining balance owed by you will be charged to your credit card, and a copy of the charge will be mailed to you. This will be an advantage to you, since you will no longer have to write out and mail us checks. It will be an advantage to us as well, since it will greatly decrease the number of statements that we have to generate and send out. The combination will benefit everybody in helping to keep the cost of health care down.This in no way will compromise your ability to dispute a charge or question your insurance company’s determination of payment. Co-pays due at the time of the visit will, of course, still be due at the time of the visit.If you have any questions about this payment method, do not hesitate to ask. Any charges over $100 will be additionally verified and approved by you via phone or other method before processing.
I authorize Southeastern Skin Cancer & Dermatology, its Doctors, and/or staff to issue charges to my credit card account (shown below) under the following circumstances:

I agree
I understand that I am responsible for payment of the following charges at the time of service: deductibles, services not covered by my insurance policy, medically unnecessary/cosmetic services, co-payments, and insurance balances from previous appointments (should my primary insurance be with a company with which Southeastern Skin Cancer & Dermatology is contracted).

I agree
If my insurance company is not one with which Southeastern Skin Cancer & Dermatology is contracted, I am responsible for the entire amount of charges at the time of service. I acknowledge that a representative of Southeastern Skin Cancer & Dermatology billing department is available to explain the charges to me and I agree with this amount.

I agree
If, after my insurance pays on my claims and a patient balance becomes due to Southeastern Skin Cancer & Dermatology, I authorize this office to generate charges to my major credit card account for that unpaid balance without further permission or notice.

I agree
I request a Receipt for Charges to be mailed to my address.

Enter your Credit Card Info

Authorize Card

$ Free

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

New Patient Registration Form

Insurance Information

PATIENT FINANCIAL POLICY AND ASSIGNMENT OF BENEFITS

New Patient Privacy & Consent

ACKNOWLEDGEMENT OF RECEIPT

Optional Credit Card Information