PATIENT FORMS
NEW PATIENT FORMS
If you are new to the practice, or have not been seen in 3 years, please print and complete the following, and bring them to your visit.
- Patient Information
- Health History and Review of Systems
- HIPAA Consent
- Financial Policy
- Insurance Cost Sharing Status
If you are being seen for a hair loss consultation, print and read the following:
RETURN PATIENT FORMS
If the calendar year has changed, or six months have passed since your last visit, please print and complete the following, and bring to your next visit.
If you are being seen for a hair loss consultation, print and read the following:
PAYMENT OPTIONS
Insurance Plans
Our practice participates in the following insurance plans:
- Blue Cross Blue Shield
- Blue Care Network
- Health Alliance Plan - Providence Group
- Medicare
- PPOM
- Smartplan
- Aetna
If you do not see your insurance plan listed here, please call us or your insurance company for more information on our participation status.
S.K.I.N. SPA PATIENTS
Print the following and bring to your next visit.
If you can't open the forms, you'll need to install the Adobe Reader. Click the button below to install:
Other Payment Options
We gladly accept the following payment types:
- New patients: Visa, MasterCard, Care Credit, cash
- Returning patients: Visa, MasterCard, Care Credit, personal check, cash
SKIN DISEASE INFORMATION
Search for details about your specific skin condition below:
