HOW DID YOU HEAR ABOUT OUR OFFICE?*
MAY WE HAVE YOUR PERMISSION TO EMAIL YOU UPCOMING PRACTICE INFO AND EVENTS?
MAY WE CONFIRM YOUR APPOINTMENTS BY TEXT?
PLEASE CHECK IF YOU ARE INTERESTED IN RECEIVING INFORMATION ABOUT:
PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE
I authorize the release of any medical and personal information necessary for my care and treatment. I authorize the release of any medical information necessary to process insurance claim(s). I authorize payment of medical benefits to the physician for service Rendered, and further understand that I am responsible for coinsurance, deductibles, and co-payment amounts as determined by my insurance carrier. Patients who carry Health Care Insurance should remember that professional services are rendered and charged to the patient and Not the Insurance Company. We will submit charges to your Insurance Company as a courtesy; however, payment of your account is your responsibility
Have You used a retinoid or accutane in the last 6 months?
DO YOU HAVE DRUG ALLERGIES?
Do you have a history of smoking greater than 20 years?
Is there any additional information relevant to your medical history that you feel is important?