New Patient Form

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PATIENT INFORMATION

Today's Date

Patient Name

Prefix First Middle Last

Social Security #

Mailing Address

Street Address City State ZIP Code

Home Phone

Cell Phone

Work Phone

Preferred Contact #

Home

Cell

Work

Okay to leave message?

Home

Cell

Work

Email Address

Date of Birth

Age

Sex

Marital Status

Parent or Responsible Party

Person responsible for this account, if different from patient

Responsible Party Name

Prefix First Middle Last

Responsible Party Date of Birth

Responsible Party Sex

Responsible Party Mailing Address

Street Address City State ZIP Code

Responsible Party Home Phone

Responsible Party Work Phone

Responsible Party Social Security #

Insurance Information

Please present insurance card(s) at time of check in

Primary Insurance

Primary Insurance Provider

Primary Policy Holder

Primary Insured's Date of Birth

Primary Insured Social Security #

Primary Insured's ID #

Primary Group #

Primary Employer Name

Primary Employer Phone

Primary Relationship of insured to patient

Secondary Insurance

Secondary Insurance Provider

Secondary Policy Holder

Secondary Insured's Date of Birth

Secondary Insured Social Security #

Secondary Insured's ID #

Secondary Group #

Secondary Employer Name

Secondary Employer Phone

Secondary Relationship of insured to patient

Emergency Contact Name

Emergency Contact Phone

Referred by

Primary Care Physician

Primary Care Physician Phone

I authorize the release of any medical information necessary to process insurance claims and authorize payment of medical benefits to the provider. I understand I am financially responsible for any charges not covered by insurance.

Patient or Responsible Party Signature (type full legal name)*

Authorization Date

HIPAA Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations.

Protected health information may be disclosed or used for treatment, payment, or health care operations.
The Practice has a Notice of Privacy Practices available for review.
The Practice reserves the right to change the Notice of Privacy Practices.
The patient has the right to restrict uses of information but the Practice does not have to agree.
The patient may revoke this Consent in writing at any time.

Printed Name of Patient*

Patient DOB

Signature of Patient or Representative (type full legal name)*

Signature Date

Relationship of Representative to Patient

Patient Phone Number

Emergency Contact

Emergency Contact Phone Number

Authorized Access to Medical Records

I give permission for the following individual(s) to have access to my medical records:

Authorized Person 1 Name

Prefix First Middle Last

Authorized Person 1 Relationship

Authorized Person 2 Name

Prefix First Middle Last

Authorized Person 2 Relationship

Authorized Person 3 Name

Prefix First Middle Last

Authorized Person 3 Relationship

Financial Policy

Payment for services is due at the time services are rendered. We accept cash, check, VISA, Discover, American Express, or Mastercard. We will process insurance claims but need a copy of your insurance card. You are responsible for co-pays if we are a provider for your plan.

Returned checks are subject to a $20.00 returned check fee.

You are ultimately responsible for your account regardless of insurance payment. If insurance has not paid within 60 days, the balance is due from the patient.

Minor Patients: Non-emergency treatment for unaccompanied minors will be denied without prior payment arrangements. Parents/guardians are responsible for payment on the day of service.

Financial Policy Signature (type full legal name)*

Financial Policy Date

No-Show Appointment Policy

Missed appointments or appointments not cancelled in an appropriate amount of time are a lost opportunity for us to help another patient. We ask that you make every effort to keep your scheduled appointment and arrive on time.

We ask that you give us 24-hour notice of cancellation or reschedule.

Effective October 1, 2024, a charge of $30.00 will be made for established patients who do not show for their appointment or do not call prior to their appointment time to cancel and/or reschedule.

Patient/Guardian Signature (type full legal name)*

Date

Patient Name (Printed)*

Signature

Guardian Name (Printed)

Signature

New Patient Paperwork - Dawkins Dermatology

PATIENT INFORMATION

Parent or Responsible Party

Insurance Information

Primary Insurance

Secondary Insurance

DAWKINS DERMATOLOGY ASSOCIATES

NEW PATIENT

Past Medical History

Skin Disease History

Demographics

Family History

Smoking Status

Review of Systems

HIPAA Patient Consent Form

Authorized Access to Medical Records

Financial Policy

No-Show Appointment Policy

Schedule Your Visit

get in touch

phone

fax

Address

hours