www.skinandlasertreatment.com - New Patient Registration Form

New Patient Registration

Please note that it is important to fill in all the fields before submitting. Thank you.
Name*

First NameMiddle NameLast Name
Birth of Date*

MonthDayYear
Age*
Sex*
SSN
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Marital Status
Telephone
Home Phone Number*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
How did you hear about us?
Referred By
Other Family Members Seen by Dr. Lee
E-Mail for billing purposes*
example@example.com
Employer
Occupation
Spouse Name
Spouse Employer
Spouse Work Phone Number
Please enter a valid phone number.
Emergency Contact
Emergency Contact / Minor Parent or Guardian*
Relationship to Patient*
Phone Number*
Please enter a valid phone number.
Person Responsible for Account
Relationship to Patient
Insurance Information
Primary Insurance
Insurance Company
Effective Date

MonthDayYear
Co-Pay
ID Number
Group Number
Type

PPO/EPO/POSHMOMedicareOther
Subscriber's Name
Social security Number
Subscriber's Date of Birth

MonthDayYear
Subscriber's Address

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth

MonthDayYear
Age
Sex
Marital Status
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Do you have secondary insurance?*

YesNo
Secondary Insurance
Insurance Company
Effective Date

MonthDayYear
Co-Pay
ID Number
Group Number
Type

PPO/EPO/POSHMOMedicareOther
Subscriber's Name
Social security Number
Subscriber's Date of Birth

MonthDayYear
Subscriber's Address

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth

MonthDayYear
Age
Sex
Marital Status
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
I certify that I (or my dependent) have insurance coverage with the Insurance Company and assign insurance benefits directly to Dr. Lee and the East Bay Laser & Skin Care Center, Inc., if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance.
Patient Signature*

Clear
Patient Name*

First NameLast Name
Date*

MonthDayYear
Should be Empty:

New Patient Registration

Telephone

Emergency Contact

Insurance Information

Primary Insurance

Secondary Insurance