INTAKE FORM Lincoln Road Dermatology

PATIENT INTAKE FORM 2025

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WELCOME TO LINCOLN ROAD DERMATOLOGY
Thank you for choosing us for your dermatologic care.
To streamline your visit, please complete the short information below.

Before your appointment, we encourage you to review our office policies:
www.lincolnderm.com/patient-resources

What to Expect at Check-In:
• You’ll check in using our iPad system and confirm or update your medical and demographic details, which are securely stored in our electronic health record (EZDERM).
• A credit card on file (CCOF) is required at check-in and cannot be bypassed.
• Please bring a valid photo ID, your insurance card, and a form of payment.
• Accepted payment methods: credit card or cash (no checks).
• Consent and financial forms will be signed during your visit.
Name

First NameLast Name
Date of birth*

MonthDayYear
Are you a new or returning patient?*
Have you already scheduled an appointment*

Yes, I have an appointmentI submitted a request and am waiting to be scheduledI need help scheduling
Last Name*
First Name*
Phone*
Please provide a cell phone number capable of receiving text messages from our office (e.g., appointment reminders, check-in instructions).
Is this phone number capable of receiving text messages?*

YesNo
E-mail*
Correspondence regarding your care will go here so please use private email.
Address*

Street Address

Include apartment

CityState / Province

Postal / Zip Code
Gender*

FemaleMaleOther
Insurance & Payment

Please let us know how you plan to pay for your visit
Insurance & Payment*

Yes, I will upload a copy of my current/active insuranceNo, I will be self pay ($200)I have insurance, but you office is out-of-network- I will pay out of pocket. ($200)
Note for Self-Pay Patients:
Self-pay fees apply only to the consultative portion of your visit. If additional services are recommended — such as lab tests, procedures, or biopsies — associated fees will be discussed with you before proceeding.
Take or upload a photo of the front of your card:*

Click "Browse Files" or "Take Photo" on your phone to upload.
Cancelof
Take or upload a photo of the back of your card:

Click "Browse Files" or "Take Photo" on your phone to upload.
Cancelof
If you have more than one insurance card, please indicate which is your primary vs. secondary insurance:
Upload photo of front of driver's license or ID

Click "Browse Files" or "Take Photo" on your phone to upload..
Cancelof
Please state the nature of your intended visit:*
To ensure proper scheduling, your visit will focus only on the concerns listed above.Please note that cosmetic concerns or consultations are not included in insurance-based medical visits. If you would like to address any cosmetic issues, a separate cosmetic appointment must be scheduled.
Who is your primary care doctor?
Please remark if doctor is not local
How did you hear about us?

FriendFamilyMy doctorInternetOther
Acknowledgment & ConsentBy signing below, I confirm that I’ve reviewed the office policies at lincolnderm.com/patient-resources, including those on communication, missed appointments, privacy (HIPAA), and billing.I acknowledge:I had the chance to upload my insurance and ID.I do not have a Medicaid-based plan.If my insurance doesn’t cover the visit, I agree to pay up to $200 for the consult, charged to my credit card on file.Additional services (labs, biopsies, procedures) may involve separate charges, which will be reviewed with me before proceeding. Signature:*

Clear
Date*

MonthDayYear
Should be Empty:

PATIENT INTAKE FORM 2025

Insurance & Payment