Dermatology Practice - Patient Registration

Dermatology Practice - Patient Registration

Please complete this form to register as a new patient at our dermatology practice. Your information will help us provide you with the best possible care.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
MaleFemaleOtherPrefer not to say
Address*
City*
State / Province*
Postal / Zip Code*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Responsible party if not the patient(parent,spouse)
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
SpouseParentSiblingChildFriendOther
Who may we discuss your care with?
What is the phone number of the person to discuss care?
May we leave personal medical information on our answering machine or voicemail?
AcneActinic KeratosisSkin Cancer (basal cell, squamous cell or melanoma)Blistering sunburnsDry skinEczemaFlaking or itchy scalpHay fever/allergiesPoison IvyPrecancerous MolesTanning bed exposureAnxietyArthritisAsthmaAtrial fibrillationBenign prostatic hyperplasiaBreast cancerColon cancerCOPDCoronary heart diseaseDepressionDiabetesEnd stage renal diseaseGERDHearing or vision lossHepatitisHigh blood pressureHigh cholesterolHyperthyroidismLeukemiaLung cancerLymphomaPregnancy (current/planning)Prostate cancerRadiation treatmentSeizuresStrokeOther
Family history of skin cancer?
Do you wear sunscreen? What SPF?
Do you smoke tobacco?
Do you require pre-medication prior to procedure?
Do you have a pacemaker?
Do you have a defibrillator?
Do you drink alcohol? If so how many per day?
If over 65 years old- Have your received your pneumonia vaccine?
If over 50 yeas old- Have you received your shingles vaccine?
Do you have someone to make medical decisions if you are unable to?
Have you received the most recent Covid vaccine available?
Current Medications*
Allergies (Medications, Food, Environmental)*
Please describe your dermatological concerns or conditions in detail.*
I have read and understand the HIPAA compliance and data usage policy of this practice. I consent to the use of my information as described in the policy.
Patient Signature*

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Date*

MonthDayYear
Date
PATIENT FINANCIAL POLICY AGREEMENT
North Branch Dermatology LLC is committed to serving our patients with the best medical care and we expect the same commitment from our patients. This includes being on time for your appointment and calling to cancel an appointment if you are unable to make it. If you do not notify us that you will not be able to attend a scheduled apointment a $25 fee may be billed to you. The patient should be redy to present their current insurance cards at every appointment and making their copay payments at the time of the office visit.

Your responsibility is to provide us with the accurate and complete information concerning your primary and secondary insurance medical benefits; including having your referral documents needed at the time of service for HMO patients. It is the patients responsibility to determine if the provider they are scheduled to see in our office is in network with their insurance plan beforehand or if their insurance requires a referral to see that provider. As a courtesy, North Branch Dermatology will file your insurance claim for you. Any deductible, co-insurance or balance left after insurance is patient responsibility to pay.

For services outside of our clinic, like radiology, laboratory, diagnostic testing of any kind and referral to outside surgeons for further treatment, it is your responsibility to know which facility you are required to use. If you aren't sure, please speak with your insurance company to inquire if those services or provider will be covered before scheduling.

I understand that my signature authorizes North Branch Dermatology to bill my insurance for my claim and also authorizes the release of medical information necessary to pay my claim to the payer. This signature is validation of my understanding of the above policy and my responsibility as a patient.
Patient Name: (Print)
Date:
Signature

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MEDICAL APPOINTMENT CANCELLATION/NO SHOW POLICY
Effective January 1st 2025 any established patient who fails to show or cancels/reschedules an appointment and has not contacted our office with at least 24 hours notic will be charged a $25 fee. There are no exceptions to this policy so please do not call the office asking for the fee to be waived at a later date.

Any established patient wh fails to show or cancels/reschedules an appointment without a 24 hour notice a second time will be charged a $50 fee.

If a third no show or cancellation/reschedule occurs without a 24 hour notice, the patient may be dismissed from the practice.

Any new patient who fails to show for their initial visit will not be rescheduled if the provider decided to do so.

The fee is charged to the patient, not the insurance company. Any no show fees must be paid prior to our scheduling any future office visits.

As a courtesy, we have a service that may text, call or email reminders for an appointment. If you do not recieve a reminder call or message, the above Policy will still remain in effect.

I have ready and understand the Medical Appointment Cancellation/No Show Policy and agree to its terms.
Printed name:
Date:
Signature

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Dermatology Practice - Patient Registration

PATIENT FINANCIAL POLICY AGREEMENT

MEDICAL APPOINTMENT CANCELLATION/NO SHOW POLICY