INTAKE FORM Lincoln Road Dermatology

PATIENT INTAKE FORM 2026

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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
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).Format: (000) 000-0000.
Is this phone number capable of receiving text messages?
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

Other
Insurance & Payment

Please let us know how you plan to pay for your visit
Insurance & Payment
Do you currently have Medicare (including due to disability or medical condition, even if you are under 65?
If yes, your Medicare is:
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?

Other
Acknowledgment & Consent By signing below, I confirm that I have reviewed the office policies at lincolnderm.com/patient-resources, including those regarding communication, missed appointments, privacy (HIPAA), and billing. I acknowledge that I had the opportunity to upload my insurance and ID.I confirm that I do not have a Medicaid-based plan. I understand that failure to disclose all active insurance coverage, including Medicare (even if under age 65), or providing inaccurate or incomplete insurance information may result in a patient-responsible balance.I agree to pay a minimum of $200 for the consult and any additional charges associated with procedures or laboratory fees, which may be 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
Date

MonthDayYear
Should be Empty:

PATIENT INTAKE FORM 2026

Insurance & Payment