New Patient Registration Form

Patient Name*

First NameMiddle NameLast NameSuffix

Preferred First Name

E-mail*

example@example.com

Would you like to opt in to our monthly email newsletter?*

YesNo

Cell Phone Number*

Please enter a valid phone number.

Alternate Phone Number

Please enter a valid phone number.

Date of Birth*

MonthDayYear

Social Security Number

Gender*

May we leave medical information on your voicemail?*

YesNo

May we discuss your medical information with family members?*

YesNo

If yes, list names:

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Marital Status

Occupation/Employer

Primary Care Physician*

Referring Physician*

Reason For Visit

In case of emergency

Emergency Contact

First NameLast Name

Relationship

Contact Number

Taking any medications, currently?*

YesNo

If yes, please list them here. Include prescriptions, over-the-counter meds (such as aspirin), vitamins and herbal products.

Allergies To Any Medications?*

YesNo

If Yes, please list medications you are allergic to and reaction

Pharmacy of Choice

Name and address

Check if you have ever had any of the following*

Any notes to add regarding your medical history

Type of cancer or medical condition not listed

Have you had skin cancer?*

YesNo

If Yes

MelanomaBasal Cell CarcinomaSquamous Cell CarcinomaYes, but I don't know the type

Locations of skin cancers, treatments/surgeries and dates

Do you have a history of any specific skin diseases?*

YesNo

If yes, please list

When you are exposed to sunlight, do you

ALWAYS burn (skin type 1)USUALLY burn (skin type 2)OFTEN burn, tan slowly (skin type 3)SOMETIMES burn, tan well (skin type 4)RARELY burn, always tan (skin type 5)NEVER burn, deeply tan (skin type 6)

Are you pregnant?

YesNo

Are you breastfeeding?

YesNo

Are you trying to conceive?

YesNo

Please list any blood relatives (parents, grandparents, siblings and children) with a history of Skin cancer or Melanoma

Do you drink alcohol?*

YesNo

If yes, number of drinks per week

Do you smoke?*

YesNo

If yes, number of packs per day

Self-PayI have Medi-Cal(Medicaid)-This is NOT Medicare

Responsible Party*

First and Last Name, Date of Birth ans SS#

Primary Insurance Company*

Please enter N/A if self-pay

Relation to policyholder*

Please enter N/A if self-pay

If patient is NOT Policyholder*

Please enter N/A if self-pay

Policyholder date of birth*

Please enter N/A if self-pay

Policyholder SSN*

Please enter N/A if self-pay

Secondary Insurance Company

Relation to policyholder

If patient is NOT Policyholder

First and last name of policyholder

Policyholder date of birth

Policyholder SSN

Registration Signature

1. We kindly request a minimum of 24 hours' notice for appointment cancellations.
General Appointments: Failure to attend your scheduled appointment or failure to cancel at least 24 hours in advance will result in a $50 fee.
Surgical & Cosmetic Appointments: Failure to attend your scheduled appointment or provide at least 24 hours' notice for cancellations will result in a $100 fee.

2. Payment is due at the time of service. It is your responsibility to pay for any deductibles, co-payments, or non-covered/cosmetic services on the day of your appointment. We accept credit cards, debit cards, checks, and cash. There is a $50 charge for checks returned for insufficient funds.

3. I understand that my insurance policy/coverage is a contract between myself and my insurance company. I understand I am ultimately responsible for the payment of services. As a courtesy to you, we will file your insurance claim if you assign the benefits to the doctor—in other words, if you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within 60 days, you are responsible for paying any outstanding balances.

4. If we are not contracted with your insurance carrier or if you do not have insurance coverage, you are responsible for payment in full at the time of service.

5. Not all insurance plans cover all services. Although policies vary among insurance companies and plans, most do not cover cosmetic services or removal of benign skin growths. In the event your insurance plan determines a service to be “not covered,” you will be responsible for the complete charge.

AUTHORIZATIONS

1. I have read and understand the practice’s financial policy and I agree to be bound by its terms.

2. I authorize the release of medical information to my primary care or referring physician, to consultants if needed, and as necessary to process insurance claims and prescriptions.

3. I have read and understand the Notice of Privacy Practices from Roseville Dermatology, Inc.

4. I authorize Roseville Dermatology, Inc. to take digital photographs for my medical record only if medically necessary.

5. I authorize my providers and staff here to view my external prescription history via the RxHub service.

Financial Policy Signature

Date

The Open Payment Database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov. For informational purposes only, a link to the federal Center of Medicare and Medicaid Services (CMS) Open Payment web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payments and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to providers and teaching hospitals be made available to the public.

Please sign below to acknowledge that you have been informed about the Open Payment Notification.

Signature

Date

How did you hear about us?*

Patient Registration Form

Medical History

Skin History

Women Only

Family History

Social History

Insurance Information

Financial Policy

Open Payment Notification