New Patient Registration Form - MINORS (UNDER AGE 18)

New Patient Registration - MINORS

Please fill out all fields below.
Patient Name*

First NameMiddle NameLast Name
E-mail*
Sex*
Date of Birth*

MonthDayYear
Please upload a photo of a government issued ID or valid form of identification of a parent/guardian ONLY

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Parental Consent Form

By law, any child under the age of 18 cannot be seen by a healthcare provider without consent from a parent or legal guardian. If a minor arrives with someone other than a parent or legal guardian, we must have written permission from the parent or legal guardian for the adult to act on your behalf.
How long is this consent valid?*

The patient may receive medical care without an accompanying adult indefinitely, until consent is revoked in writing.The patient may NOT receive medical care without an accompanying adult.
For those occasions when a parent/guardian are unable to accompany the minor to his/her appointment, please list the names of individuals who may give us consent to see the minor. FIRST INDIVIDUAL:

First NameLast Name
Relationship to Patient
Contact Number:

Area CodePhone Number
For those occasions when a parent/guardian are unable to accompany the minor to his/her appointment, please list the names of individuals who may give us consent to see the minor. SECOND INDIVIDUAL:

First NameLast Name
Relationship to Patient
Contact Number:

Area CodePhone Number
Limitations: Please specify any limitations on the kinds of medical services for which this authorization is given. (If none, state none.)*
Authorization*
Name of Parent or Legal Guardian Completing this Form*

First NameLast Name
Relationship to Patient *
Signature*

Clear
Date*

MonthDayYear
Date
Patients Social Security Number
Marital Status*
Patient Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
Work Phone Number

Area CodePhone Number
May we leave detailed messages about your care on the following lines?*

Ok to leave message on home lineOk to leave message on cellOk to leave message on work lineI do not authorize McLean Dermatology to leave detailed messages about my care
Emergency Contact Information
Emergency Contact:*

First NameLast Name
Relationship to Patient*
Emergency Contact Number*

Area CodePhone Number
Billing Information

Please bring a photo ID and your insurance card to your appointment. Note: If you do not have insurance or are not using insurance for your visit, payment is due at the time of your visit.
***IT IS OUR POLICY THAT WE PERFORM ONLY ONE MEDICAL PROCEDURE - BILLED UNDER YOUR INSURANCE - PER OFFICE VISIT; REGARDLESS OF THE TYPE OF PROCEDURE IT IS.
Do you have active health insurance?*

YesNo
Name of Primary Health Insurance Company
Primary Insurance ID Number
Name of Policy Holder

First NameLast Name
Policy Holder's Date of Birth

MonthDayYear
Patient's Relationship to Primary Insurance Policy Holder
If you are the policy holder, please write SELF.
Please upload a photo of the FRONT of your primary insurance card.

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Please upload a photo of the BACK of your primary insurance card.

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Does your insurance require a specific Lab/Clinic for pathologies? If unsure, please contact your insurance.*

YesNo
If yes, please list where:
Name of Secondary Health Insurance Company (If applicable)
Secondary Insurance ID Number
Name of Secondary Policy Holder

First NameLast Name
Secondary Policy Holder's Date of Birth

MonthDayYear
Relationship to Secondary Policy Holder
If you are the main policy holder, please write SELF.
Please upload a photo of the FRONT of your secondary insurance card.

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Please upload a photo of the BACK of your secondary insurance card.

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Does your insurance require referrals to specialists?*

YesNo
Name of Referring Physician (If Applicable)
*Please note: If your insurance requires referrals, you must obtain the referral prior to your visit. Referrals must be processed through your insurance and have an authorization number to be valid. **Referrals for McLean Dermatology and Skincare Center may be faxed to us prior to your visit at (703) 388-0873, or emailed to info@mcleandermatologycenter.com ***Referrals for Potomac Dermatology and Skincare Center may be faxed to us prior to your visit at (703) 388-0873, or emailed to info@potomacdermatologycenter.com
Referring Physician Phone Number (If Applicable)

Area CodePhone Number
Your Care Team
Name of Primary Care Physician
Primary Care Physician Phone Number

Area CodePhone Number
Preferred Pharmacy Name
Preferred Pharmacy Phone Number

Area CodePhone Number
Preferred Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list the names and relationships of individuals who we may speak to about your medical records and billing matters related to your account. (Please note: if no one is listed here, we will not be able to discuss your account with anyone other than you.)*
Health History
Please list the names of any medications you currently take, including over-the-counter medications. If you are not taking medications, please write "No medications."*
If you have a medication list, please feel free to upload a copy of it here:

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Do you have drug allergies? Please list the names of medications you are allergic to here. If you do not have drug allergies that you are aware of, please write "No known allergies."*
Do you have any of the following health conditions? Select all that apply.*

Abdominal PainAllergy to Topical Antibiotic OintmentsAllergy to AdhesiveAllergy to Cow Milk ProteinAllergy to LatexAllergy to LidocaineAnxietyArthritisArtificial Heart ValveArtificial Joints within Past 2 YearsAtrial Fibrillation (Irregular Heartbeat)Bloody StoolBloody UrineBreastfeedingCancerChanging MoleChest PainCoronary Artery DiseaseCoughCurrently taking Blood ThinnersDefibrillatorDepressionDiabetesEczemaEnd State Renal DiseaseFever or ChillsGI Upset with AntibioticsHay Fever/AllergiesHeadachesHearing LossHepatitisHigh Blood PressureHigh CholesterolHIV/AIDSHyperthyroidismJoint AchesImmunosuppressionKidney DiseaseMastectomy - Left SideMastectomy - Right SideDouble MastectomyMuscle StiffnessMuscle WeaknessOrgan TransplantPacemakerCurrently PregnantPlanning a PregnancyProblems with BleedingProblems with Scarring (Hypertrophic Scars or Keloids)PsoriasisRapid Heartbeat with EpinephrineRequire Premedication Prior to ProceduresRashSeizuresShortness of BreathSore ThroatThyroid ProblemsTuberculosisUnintentional Weight LossWheezingYeast Infection with AntibioticsTanning Bed UseLiver DiseaseFormer SmokerCurrent SmokerAlcohol UseRecreational Drug UseNone of these
Please list all other pre-existing health conditions, if applicable.
Please list all previous surgeries
Have you had skin cancer?*

No I have not had skin cancerYes, history of Basal Cell Carcinoma (BCC)Yes, history of Squamous Cell Carcinoma (SCC)Yes, history of Melanoma
Has anyone in your family had skin cancer?*

No family history of skin cancerYes, family history of Basal Cell Carcinoma (BCC)Yes, family history of Squamous Cell Carcinoma (SCC)Yes, family history of Melanoma
Please specify which family members have had skin cancer.*
Cosmetic Concerns

(Optional)
I would like to know more information about the following skincare products?

Eye CreamsSunscreenRetinolsCleansersScar CreamsMoisturizersAnti-Aging SerumsAnti-Aging Moisturizers
I have the following cosmetic concerns:

Aging SkinDownturned MouthFine Lines/WrinklesAge Spots/Brown Spots/Sun spots/Skin DiscolorationWeight Loss ($500 Evaluation & Labs Only)Under eye circlesUnwanted fat on the belly/love handles/back/armsCrows FeetLoose Skin/Sagging SkinLoss of Facial VolumeUneven Skin TextureAcne ScarringFacial RednessUrinary Incontinence
I would like more information about the following cosmetic procedures:

Botox, Dysport, or XeominAnti-Aging Lasers (Fine Lines/Wrinkles)Fillers to Soften Facial/Hand/Neck LinesLasers to Reduce Facial RednessSclerotherapy (Spider/Varicose Veins)Latisse (Eyelash/Eyebrow Growth)Skin TighteningTreatment Options for Excessive SweatingKybella (Injections for Permanent Reduction of Chin Fat)CoolSculpting; A non-surgical fat reduction treatment. (If you would like a complimentary CoolSculpting consultation, please notify our staff and mention areas of concern - see images below.) (THIS SERVICE IS ONLY AVAILABLE AT MCLEAN DERMATOLOGY - NOT POTOMAC DERMATOLOGY).
How did you hear about McLean & Potomac Dermatology and Skincare Center?*

Family/Friend (Please write name in "Other" box)Insurance CompanyPhysicianSocial MediaPublication (medical journal, magazine article, etc.)
Financial Agreement
Financial Agreement

At McLean & Potomac Dermatology and Skincare Center, we are committed to providing the best dermatologic care.

This agreement must be signed in order to be seen by providers at McLean & Potomac Dermatology and Skincare Center

OFFICE FEES AND PAYMENTS

A.     There are fees for all services performed by our providers and staff, including consultations and procedures.

B.     As the patient or guarantor, you are responsible for all charges for your visits, including co-‐payments AT TIME OF SERVICE, deductibles, and coinsurance amounts that are due per your insurance plan.

C.     OUR OFFICE POLICY REQUIRES A CREDIT CARD TO BE PUT ON FILE AND WILL ONLY BE CHARGED FOR ANY OUTSTANDING BALANCES, AFTER INSURANCE PAYMENTS HAVE PROCESSED – BY THE BILLING DEPARTMENT.

D.    Cosmetic services cannot be processed through insurance, and fees for such services are due at the time of service. All sales are final.

E.     General dermatology services will be processed through the insurance on file or payment is due at time of service by the patient – if no insurance is on file.

F.     If there is a balance due after insurance pays for your visit, the difference owed is patient responsibility.

G.    Charges for all visits and procedures that are not processed by insurance are due at the time of service.

H.    Medicare patients are responsible for any balances due for services that are not covered by Medicare.

I.      If you have an outstanding balance on your account, it must be paid in full before your next visit.

J.     We accept cash and all major credit cards. We do not accept checks.

K.    For any NSF check (checks returned for non-‐sufficient funds), a $50 NSF charge will be billed to your account.

L.     If proof of insurance is not provided at the time of service, you are responsible for the entire fee for the consultation and/or procedure at the time of service.
In the case of an account overpayment, a credit will remain on your account unless you request a refund.

INSURANCE POLICIES

A.     Your insurance policy is a contract between you and your insurance company. It is essential that you understand which services and procedures are covered by your insurance plan and obtain any necessary authorizations or referrals prior to your appointment with us.

B.     We accept plans through the following payers as in-network providers: Aetna, Anthem BCBS, Federal BCBS, Carefirst Blue Choice, Cigna, United Healthcare, GEHA, UMR, Medicare.

C.     We cannot guarantee that we accept your specific plan as an in-network provider; it is your responsibility to verify your insurance benefits and coverage prior to your visits.

D.    We will not submit claims to any other insurance company other than those listed above. If you have a secondary insurance in addition to one of the plans listed above, we will file a claim to your secondary insurance as an out-of-network provider. In such instances, we cannot guarantee complete coverage.

E.     If we do not accept your insurance, the charges for all services are due in full at the time of service. All sales are final.

F.     Please note: several United Student Resources plans do not cover hair loss visits; verify your coverage and benefits prior to your visit so you are aware of your plan benefits and limits.

G.    It is your responsibility as the patient to understand your insurance plan limits and restrictions that affect coverage of services you receive.

H.    If you have biopsy or any lab testing in our office, you and/or your insurance will be billed for the corresponding lab charges. The lab is a third party and will bill you for remaining balances. THE THIRD PARTY LAB FOR PATHOLOGY IS FAIRVIEW LAB IN MINNESOTA. OUR OTHER THIRD PARTY FACILITY FOR ALL OF OUR LAB TESTING IS LabCorp.

I.     If your insurance company requires you to use a specific laboratory in order for laboratory fees to be covered, it is your
responsibility to request this.

48-HOUR CANCELLATION POLICY

A.     You will be billed a $50 “No Show/Cancellation Fee” for each appointment cancelled or missed without 48-hour notice.

B.     You will be billed a $150 “No Show Fee/Cancellation” for all procedure appointments cancelled or missed without 48-hour notice (Excisions, surgeries, etc.)

COLLECTIONS

In the event that your account is put into collections, the balance must be paid in full – in order to schedule any future office appointments or even request prescription refills.

PRIVACY PRACTICES

A.     By signing below, you authorize the release of any medical or other information necessary to process claims related to general dermatology (medical) services received by yourself or your dependent. You assign all medical payment on your behalf or that of your dependent for services provided to be issued to McLean Dermatology and Skincare Center, PLLC, 6849 Old Dominion Dr., Suite 450, McLean, VA 22101; or issued to Potomac Dermatology and Skincare Center, PLLC, 9812 Falls Road, Suite 124, Potomac, MD 20854.

We are required by law to provide you with a copy of our Notice of Privacy Practices and our Financial Agreement.

By signing this agreement, you acknowledge that you have received and read our Notice of Privacy Practices and fully understand and accept the terms of the McLean & Potomac Dermatology and Skincare Center Notice of Privacy Practices and Financial Agreement.
Signature of Guardian/Parent For Financial Agreement:*

Clear
I have received and read the Notice of Privacy Practices, and dully understand and accept the terms of the McLean & Potomac Dermatology and Skincare Center Notice of Privacy Practices.*
Patient Name*

First NameLast Name
Parent/Guardian Name if Patient is Under the Age of 18*

First NameLast Name
Signature*

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

New Patient Registration - MINORS

Parental Consent Form

Emergency Contact Information

Billing Information

Your Care Team

Health History

Cosmetic Concerns

Financial Agreement