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Patient Form

Please Fill Out All Form Info Below

Name(Required)
Home Address(Required)
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Pharmacy Info

Pharmacy Address
Insurance Address
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Business Address
Emergency Contact Address

Please Confirm all info

Please note Dr. Green is not contracted with any insurance company. Please contact your individual insurance carrier to confirm what your individual out of network benefits are. The initial consultation fee is $450.00 and can be applied towards any cosmetic treatment within 3 months. A 48-hour notice is required for cancellation otherwise patient is responsible for a $450 cancellation fee for new patients and $100 for existing patients. Payment is due when services are rendered.

Questionnaire

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 Policy & Cancellations

It is our office policy to have 48 hour cancellation notice otherwise an office visit fee of $100.00 will apply for existing patients and $450 for first time patients. Missed appointments without notification will automatically be charged an office visit fee. Payment is expected at the time of visit. After 90 days all outstanding bills will automatically be forwarded for collection. All bounced checks will incur a $20.00 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

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. I agree that the images may be:
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)

Call Us (212) 535-3088