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Patient Form

 

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Pharmacy Info

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Please Confirm all info

Please note that Dr. Green is not contracted with any insurance company. Please contact your insurance provider to confirm your out-of-network benefits. The initial consultation fee is $750 and can be applied toward any cosmetic treatment within 3 months. If the consultation is for a medical procedure, an HCFA will be provided for you to submit to your insurer. Cosmetic procedures cannot be credited against a medical consultation. A 48-hour notice is required for cancellations; otherwise, the patient is responsible for a $750 cancellation fee for new patients and $200 for existing patients. Payment is due at the time of service.
Consent(Required)

Questionnaire

To help give you the best possible care, please carefully complete all questions on this form. Please confirm if you have any of the following
Liver disease or gall bladder disease(Required)


Duodenal or peptic ulcer(Required)


Lung disease(Required)


Other intestinal disease or colitis(Required)


Stroke(Required)


Heart disease(Required)


High blood pressure(Required)


Urinary or bladder problem or infection(Required)


Kidney disease(Required)


Venereal disease(Required)


Arthritis, joint problem, bone disease(Required)


Blood disorder or lymph gland disorder(Required)


Eye disease (glaucoma, cataract)(Required)


Thrombophlebitis(Required)


Frequent infections(Required)


Cancer(Required)


Neurological disorder(Required)


Emotional or psychiatric problem


Have you or any family members had Hay Fever?(Required)


Have you or any family members had Eczema?(Required)


Have you or any family members had Asthma?(Required)


Have you or any family members had Hives?(Required)


Have you or any family members had Diabetes?(Required)


Have you or any family members had Psoriasis?(Required)


Have you or any family members had Skin cancer?(Required)


Have you or any family members had Glaucoma?(Required)


Also include any allergies to medications
Have you had radiation?(Required)


Please include any types of moisturizers, sun-block, serum, acne treatment and topical medications.
Are you allergic to any medicines(Required)


For Women Only

Have you had vaginal yeast infections?


Are you pregnant?


Are you planning a pregnancy?


Note

Please inform Dr. Green at any time if you do plan to or become pregnant during your treatment period.

At the time of your first visit to this office, it is necessary for your entire skin to be examined. This will enable Dr. Green to see not only the particular skin condition for which you are consulting us, but also other skin problems of which you may not be aware.

You will be provided with a proper gown for your examination.

If for any reason you do not wish to have such a general examination of your skin, please tell Dr. Green and she will make a note on your chart regarding your wishes.

Doctor / Medical Contacts

Dear Patient, in order to help you keep your medical history up to date, please list all physicians you would like us to send your pathology and lab reports to.

Medical Contact 1: Address


















Medical Contact 2: Address


















Office Billing Policy & Cancellations

Please note that Dr. Green is not contracted with any health insurance company. Please contact your insurance provider to confirm your out of network benefits.

The initial consultation fee is $750 and can be applied towards any cosmetic treatment within 3 months.

If the consultation is for a medical procedure, an HCFA will be provided for you to submit to your insurer.

Cosmetic procedures cannot be credited towards a medical consultation.

The consultation fee cannot be applied towards any cosmetic products available in the office. The follow up fee for cosmetic treatment is dependent on the procedure performed during the visit. The follow up office visit fee is $500, if you are on Accutane, the monthly office visit fee for monitoring is $650. Any additional medical or cosmetic procedure performed will be an additional charge.

It is our office policy to have a 48-hour cancellation notice; otherwise, a missed appointment fee of $200.00 will apply for existing patients and $750 for new patient consultations.

Missed appointments without notification will automatically be charged a missed appointment fee.
Payment is expected at the time of the visit. After 90 days all outstanding bills will automatically be forwarded for collection.

All bounced checks will incur a $30.00 fee.

All unpaid balances will accrue a finance charge of 3% per month and a $3.00 billing charge. I hereby authorize Dr. Michele S. Green, M.D., P.C. to charge to the below account, any outstanding balance. In the event that fees are not paid as delineated above, I agree to pay any and all collection and/or attorney’s fees incurred.

Name on Card(Required)







Privacy Policy

Email Consent(Required)
Privacy Policy Consent(Required)

Medical Photography Consent Form

I consent to medical images and/or videos to be made of me. I agree that duplicates may be made for the referring doctor.
By signing this form below I confirm that this consent form has been explained to me in terms which I understand.

I consent for these photographs and/or videos to be used in medical publications, including medical journals, textbooks, and online/offline electronic publications. I understand that the image may be seen by members of the general public, in addition to scientists and medical researchers that regularly use these publications in their professional education. Although these photographs and/or videos will be used without identifying information such as my name, I understand that it is possible that someone may recognize me. I also agree for my image to be shown for teaching purposes and to be used for my medical record.

Placed in my medical record for future treatment(Required)


Electronically emailed to my treating health professional(Required)


Used by health professionals for education and training(Required)


Used in paper or electronic health publications(Required)


Used in commercial broadcast(Required)


Used in internet or for marketing(Required)


By signing below, I confirm that I understand this photo consent form.(Required)

Laboratory Informed Consent Form

There is no charge at the office of Dr. Michele Green to draw your blood. LabCorp will send you a bill for any testing performed. The LabCorp fee will be dependent upon your insurance company and deductible.
We are happy to provide you with a lab requisition form at your request should you prefer to have your blood drawn at a lab of your choice.
By signing below, I confirm that I understand this laboratory consent form.(Required)

Prescription Informed Consent Form

You can obtain prescription refills by contacting our office via telephone or email. Prescriptions are sent electronically to the pharmacy of your choice.
Maintenance medications, such as oral medications and topicals, can be renewed if you have had an office visit within the last 6 months. If you have not been seen in 6 months, you will need to schedule an appointment for an office visit to obtain a prescription refill. However, some patients may need labs or office visits more frequently. Please note that an office visit fee of $500 will apply, while patients on Accutane will incur a monthly office visit fee of $650 to process your medication and evaluate your progress.
We do not control the cost of medications. The price of medications is determined by your insurance company, your prescription benefit plan, and their agreement with the pharmacy you have chosen. If you are experiencing any issues with your prescription, such as cost, quantity, instructions, or coverage, please call our office during normal business hours. If you need assistance after hours, you can send us an email, and we will follow up with you and your pharmacy the following business day. We are closed on weekends, and any pharmacy issues will be addressed on Monday when the office reopens at 8:30 am.
Please be aware that antibiotics cannot be refilled, as an office visit is required every 3 months per NYS law.
Refills can only be authorized for medications prescribed by Dr. Green. We cannot refill medications prescribed by other physicians.
By signing below, I confirm that I understand this prescription consent form.(Required)

New Patient Consultation Policy

Please read this document carefully before signing. It describes our Consultation Fee Policy, clarifies when consultation fees may be applied toward future services, and outlines circumstances under which fees are non-refundable and non-transferable. Your signature confirms that you have read, understood, and agree to this policy.

1. Consultation Fee

Our practice charges a consultation fee of $750 for all new patient appointments and clinical evaluations. This consultation fee is collected at the time of scheduling your visit and covers the time, expertise, and resources required to conduct a thorough evaluation of your health concerns and treatment goals, regardless of whether any procedure or treatment is subsequently performed. Please note that patients who have not been seen in our office in over 3 years are considered new patients.

Because we are an out-of-network practice that does not bill or accept health insurance, all fees are the responsibility of the patient. While the consultation fee is required at the time of scheduling to secure your appointment, any additional fees for treatments or procedures are due at the time of service.

2. When the Consultation Fee May Be Applied Toward a Future Service

As a courtesy to our patients, the consultation fee may be credited toward the cost of a cosmetic procedure under the following conditions:

  • The visit is exclusively cosmetic in nature — meaning the consultation involved no medical evaluation, diagnosis, or treatment of any health condition.
  • You schedule and complete the cosmetic procedure within 90 days of your consultation.

If all of the above conditions are met, the consultation fee paid will be deducted from the total cost of your cosmetic procedure at the time of service.

3. When the Consultation Fee is Non-Refundable and Cannot Be Applied

The consultation fee is non-refundable and cannot be applied toward any future service — cosmetic or otherwise — in the following circumstances:

a) Medical Visit

If your visit involved any medical evaluation, diagnosis, treatment planning, prescription, referral, or discussion of a health condition, the appointment is classified as a medical visit. The consultation fee for a medical visit is non-refundable and cannot be applied toward any cosmetic or medical procedure.

b) Combined Medical and Cosmetic Visit

If your visit included both medical and cosmetic components — for example, if a skin concern was evaluated for both medical and aesthetic reasons, or if a medical issue was addressed during the same appointment as a cosmetic discussion — the visit is classified as a combined visit. The consultation fee for a combined visit is non-refundable and cannot be applied toward any future service, including cosmetic procedures.

c) No-Show or Late Cancellation

If you fail to attend your scheduled appointment or cancel with fewer than 48 hours of notice, the consultation fee is forfeited and will not be refunded or credited.

4. Classification of Visit Type

The classification of your visit (cosmetic, medical, or combined) is determined by the Doctor based on the nature of the evaluation performed during your appointment. This determination is made at the time of service and is not subject to retroactive reclassification based on treatment decisions made after the visit.

If you have questions about how your visit will be classified before your appointment, please contact our office in advance.

5. No Insurance Billing or Reimbursement

Our practice does not bill health insurance for any services, including those that may have a medical component. We do provide a completed HCFA form for your submission to your insurance company with all the medical codes for out of network insurance processing. All fees paid are out-of-pocket and are the sole financial responsibility of the patient.

PATIENT ACKNOWLEDGMENT

By signing below, I acknowledge and agree to the following:

  • I have read and understand the Consultation Fee Policy in its entirety.
  • I understand that the consultation fee may only be applied toward a cosmetic procedure if my visit is exclusively cosmetic in nature.
  • I understand that the consultation fee is non-refundable and non-transferable for any medical visit or any visit that combines medical and cosmetic elements.
  • I understand that the classification of my visit is determined by the treating clinician and is final.
  • I agree that I will not seek a refund of the consultation fee based on the nature of my visit or the treatment provided.