• PATIENT REGISTRATION FORM

    Please complete the following information to the best of your ability. Be sure to bring your driver's license or other photo ID to the office with you on the day of your appointment.
  • Date of birth:*
     / /
  • Sex:*
  • Marital status:
  • Race:
  • Ethnicity:
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Payment: Our professional services are rendered for and charged directly to you, not your insurance company and you agree to be responsible for payments. Payment may be made by CASH, CHECK OR CREDIT CARD. You agree that cosmetic services will not be billed to your insurance company and that you are responsible for full payment before or at the time of service.

    Outside Services: Independent outside laboratory services (e.g. Quest Diagnostics) will bill you directly for any lab work.

    Signature on File: I, the undersigned, acknowledge receipt of a copy of this office's Notice of Privacy Practices (HIPAA) and Payment Policy, consent to receive calls at the number(s) provided above, consent to examination and treatment and agree to be financially responsible for the services rendered.

  • Date:*
     / /
  • Relationship:*

  • MEDICAL HISTORY

  • MEDICATION HISTORY

  • Are you allergic to any of the following?*
  • Do you pre-medicate prior to surgeries?*
  • Are you currently taking any medication?*
  • Do you have a pacemaker or internal defibrillator?*

  • SOCIAL HISTORY

  • Do you smoke or vape?*
  • Do you use recreational drugs?*
  • Do you drink alcohol?*

  • FAMILY HISTORY

  • Living status for your Mother:*
  • Living status for your Father:*
  • Rows

  • REVIEW OF SYSTEMS AND PAST MEDICAL HISTORY

  • Rows
  • Rows
  • Date of last eye exam
     / /
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows

  • FOR MALE PATIENTS ONLY

  • FOR FEMALE PATIENTS ONLY

  • Are you currently pregnant?
  • Date of last menstrual period:
     - -
  • Date of last mammogram:
     / /
  • Date of last PAP smear:
     / /

  • PAYMENT POLICY

  • Thank you for choosing Pocono Medical Care, Inc. / MilfordMD Cosmetic Dermatology Surgery & Laser Center as your healthcare provider.  We are committed to providing you with quality and affordable health care.  Please read this policy, ask us any questions you may have and sign in the space provided.

           Insurance:  MilfordMD does not participate with any insurance company. All costs for services rendered are your responsibility and due at the time of service.

         Non-Payment:  If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full.  Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from the practice.  If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative medical care.  During that 30 day period, your physician will only be able to treat you on an emergency basis.

         Missed Appointments:  Our policy is to charge for scheduled appointments not cancelled or rescheduled within 24 hours prior to the appointment.  These charges of $25.00 for medical office visits, $50.00 for MediSpa services, $150.00 for laser/cosmetic procedure fees up to $999.00, and $500.00 for laser/cosmetic procedure fees from $1,000.00-$4,999.00 will be your responsibility and billed directly to you. All laser liposculpture procedures missed appointment charges are outlined in our Surgical Cosmetic Procedure Financial Policy.  Please help us to serve you better by keeping your scheduled appointment(s).

         Deposits:  A deposit will be required to secure your next cosmetic procedure.  If the appointment is not cancelled or rescheduled within 24 hours, you will lose your deposit.

         Refunds:  Any credit card refund will be less a 5% processing fee. Refunds made for amounts paid by check will be less a 5% processing fee.

         Return Check Fee:  $35.00

  • Date*
     / /

  • COMMUNICATIONS CONSENT

  • I consent to receive calls and text messages from Pocono Medical Care, Inc. / MilfordMD Cosmetic Dermatology Surgery & Laser Center for my protected healthcare and other services at the phone number(s) listed on the registration sheet, including my wireless number provided.

    I understand I may be charged for such calls by my wireless carrier and that such calls may be generated by an automated dialing system to confirm appointments.

    I also consent to receiving e-mails from Pocono Medical Care, Inc. / MilfordMD Cosmetic Dermatology Surgery & Laser Center to confirm my appointment(s) and/or informing me of upcoming seminars and specials.

  • Please indicate your preferred delivery method(s) for the following communications. Check all that apply for each communication.*
  • Date*
     / /

  • COSMETIC INTEREST QUESTIONNAIRE

    Please complete the following to help us better understand your aesthetic goals and needs.

  • Check off the items below that bother you, or you would like to improve.

  • FACIALS CONCERNS:
  • BODY CONCERNS:
  • Have you had any previous cosmetic treatments or procedures?
  • Would you like to learn more about our MediSpa services & skin care products?
  • Image field 98
  •  
  • Should be Empty: