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.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Emergency Contact
Emergency Contact / Minor Parent or Guardian
Relationship to Patient
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Person Responsible for Account
Relationship to Patient
Insurance Information
Primary Insurance
Insurance Company
Effective Date

MonthDayYear
Co-Pay
ID Number
Group Number
Type

Other
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.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you have secondary insurance?
Secondary Insurance
Insurance Company
Effective Date

MonthDayYear
Co-Pay
ID Number
Group Number
Type

Other
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.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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
Patient Name

First NameLast Name
Date

MonthDayYear
Should be Empty:

New Patient Registration

Telephone

Emergency Contact

Insurance Information

Primary Insurance

Secondary Insurance