New Patient Registration

  • New Patient Registration

    For patients whom have appointments already scheduled
  • Do you already have an appointment scheduled?*
  • Appointment Date*
     / /
  • Birth Sex:*
  • Marital Status:*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Insurance Information

  • PRIMARY

  • Secondary

  • Acknowledgement of Receipt of Privacy Notice
    By signing below, I hereby acknowledge that I am aware of the Privacy Practices that Affiliated Troy Dermatologists has in place. I can request a copy of this privacy agreement for my records at any time.

  • Date*
     / /

  • Authorized Persons Allowed to Receive Confidential Information

  • Do you wish to give personal information to anyone in the event that they call and have questions regarding medical condition(s)?*

  • I,{patientsName} , authorize Affiliated Troy Dermatologists to give personal information to the following people in the event that they call and have questions regarding medical condition(s):

  • I, {parentguardianName}, {patientsName}'s parent/guardian, authorize Affiliated Troy Dermatologists to give personal information to the following people in the event that they call and have questions regarding medical condition(s):

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • I have read and understand the above and allow Affiliated Troy Dermatologists to give personal information to the above listed persons.

  • Date*
     / /

  • Assignments of Benefits

  • As the patient or parent/guardian of the patient, I agree to the following:

    • The use of this form on all insurance submissions.
    • The release of information to my/the patient’s insurance companies.
    • The responsibility for my/the patient’s bill.
    • The doctor may act as my/the patient’s agent in helping to obtain payment from the insurance companies.
    • A copy of this authorization to be used in place of the original.
    • The doctor may file a complaint to the insurance commissioner on my behalf.
    • The doctor may notify the insurance companies, when their policy prohibits payment to the physician directly, to mail the checks made out to me to their office address.
    • Regardless of the divorce decree whoever brings in the minor is responsible for payment.
      I have read and understand all of the above statements and agree with their provisions.
  • Date*
     / /

  • Patient Intake

  • Marital Status*
  • Format: (000) 000-0000.
  • Do you have a primary care physician?*
  • Past Medical History (Please check all that apply)*

  • Past Surgical History (Please check all that apply)*

  • Skin Disease History*

  • Do you have a family history of Melanoma?*
  • Which Relative(s)*

  • Do you wear sunscreen?*
  • Do you tan in a tanning salon?*
  • Have you tanned in the past?*
  • Are you taking any medications currently?*
  • Are you allergic to any medications that you know of?*
  • Do you have a family history of (Select all that apply):*

  • Review of Systems

    Select all that apply:
  • *
  • ALERTS:*
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