Patient Form

Please note – by filling out this form, your credit card will not be charged until we confirm an appointment time with you. Initial consultation fee of $750 is non refundable unless 48 hour written cancellation notice is provided.

Please Fill Out All Form Info Below

Name(Required)

First

Last

Home Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Mobile Phone(Required)

Home Phone

Email(Required)

Preferred Contact Method

Reason for Visit(Required)

Instagram ID

Sex

Martial Status

Birth Date(Required)

Birth Place

Age

Social Security Number

Patient Status(Required)

Referred By(Required)

Pharmacy Info

Pharmacy Name

Pharmacy Phone(Required)

Pharmacy Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Name & Telephone of Internist

Medical Insurance Name

Insurance Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Primary Care Holder’s Name

Primary Care Holder Birth Date

Insurance ID number

Group number

Business Name

Business Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Name of Employer(Required)

Work Phone Number(Required)

Emergency Contact (Name and Relationship)(Required)

Emergency Contact Phone(Required)

Emergency Contact Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Please Confirm all info

Please note that 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 medical or cosmetic consultation fee is $750.00. Following a medical consultation, you will be provided with a HICFA form that you can submit directly to your insurance company. For a medical consultation, your $750.00 consultation fee is not transferable to any cosmetic or medical procedure. If your initial visit is cosmetic in nature, the initial consultation fee may be applied towards a cosmetic treatment within the first three months of your visit. The consultation fee is not, however, to be applied to any medical treatment or products available in the office. The follow-up fee for a cosmetic treatment is dependent on the procedure performed during the visit. The follow-up fee for a medical visit is $500.00. If you are on Accutane, the monthly office visit fee is $650.00. Any additional medical or cosmetic procedure performed will be an additional charge. If you have decided to have a complete skin examination, we would like you to be aware that for each mole removal there is a fee of $400. The mole is then sent to the laboratory for examination and you will receive a separate invoice from the pathology lab that is independent of our office. The following list is a list of the laboratories and the insurances which they contract with. Our office sends Dermatology (biopsy results) to the Ackerman Academy and Blood/Cultures to Quest and LabCorp. If your health insurance does not cover these laboratories, you may choose a different lab to send your specimens to. Please make Dr. Green or her assistant aware of your choice at the time of your visit. Thank you very much for your assistance.

Questionnaire

Please confirm if you have any of the following

Liver disease or gall bladder disease(Required)

Yes

Duodenal or peptic ulcer(Required)

Yes

Lung disease(Required)

Yes

Other intestinal disease or colitis(Required)

Yes

Stroke(Required)

Yes

Heart disease(Required)

Yes

High blood pressure(Required)

Yes

Urinary or bladder problem or infection(Required)

Yes

Kidney disease(Required)

Yes

Venereal disease(Required)

Yes

Arthritis, joint problem, bone disease(Required)

Yes

Blood disorder or lymph gland disorder(Required)

Yes

Eye disease (glaucoma, cataract)(Required)

Yes

Thrombophlebitis(Required)

Yes

Frequent infections(Required)

Yes

Cancer(Required)

Yes

Neurological disorder(Required)

Yes

Emotional or psychiatric problem

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

Any additional info

Have you had previous difficulty with wounds healing, overgrown scars, keloids or any previous skin issues that required care of a dermatologist (please explain below)

Also include any allergies to medications

Have you had radiation?(Required)

Yes

Please list all current medications (including over the counter) you are currently or have recently taken

Which topical creams or medications are you currently using?

Please include any types of moisturizers, sun-block, serum, acne treatment and topical medications.

Are you allergic to any medicines(Required)

Yes (please list below)

List allergic medicines

Please list any prior hospitalizations and surgery

Which cosmetic procedures have you had in the past?

For Women Only

Have you had vaginal yeast infections?

Yes

Are you pregnant?

Yes

Are you planning a pregnancy?

Yes

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: Name

Medical Contact 1: Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Medical Contact 2: Name

Medical Contact 2: Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Office Policy & Cancellations

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 $750.00 for new patients. 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 $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.

Method of Payment(Required)

Name on Card(Required)

First

Last

Credit Card Number(Required)

Expiration Date MM/YY(Required)

Drivers License or State ID Number

Drivers License Or State ID: Which State

Drivers License or State ID Expiration Date

Privacy Policy

I agree to the privacy policy

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information (“PHI”) about you. You have the right to review our Notice and ask questions about our privacy practices. As provided in our Notice, the terms of our Notice may change. If we change our Notice, you may obtain a revised copy by calling (212) 535-3088. You have the right to request that we restrict how PHI 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 are bound by our agreement. By signing this form, you acknowledge that you have received our Notice of Privacy Practices.

This notice describes how medical information about you may be used and disclosed, and how you can obtain access to this information. We are required by law to protect privacy of your health information and to provide you with this notice which describes our privacy practices. Please review it carefully. If you have any questions please contact our office administrator.

We are required to obtain a one-time consent from you, before we use or share your health information with others. Such disclosure will be for the sole purpose of providing treatment to you, obtain payment for our services, and running our business operations. You may revoke this consent at any time by the use of disclosure of your health information for purposes other than those stated in consent. Written authorization is not required for the following situations:

Your health information may be disclosed to:

– Doctors or medical personnel who are involved in taking care of you or doctors to whom you have been referred for other treatment.
– Your insurance company, in order to obtain reimbursement for services rendered, or to obtain pre-approval for your treatment.
– Our business associates who need the information in order to assist us with obtaining payment or carrying out our business operations (in these cases, we will have a written contract with our business associates which they will ensure that they will also protect the privacy of your health insurance.)
– Family and individuals involved in your care.
– Authorized public health officials, so that they may carry out their public health activities, including the review or reports of abuse, neglect, or domestic violence.
– Government agencies authorized to conduct audits, investigations, and inspections of our facility.
– A person or company that is registered with the Food and Drug Administration.
– Law enforcement officials, authorized federal officials, or if you are a member of the Armed Forces, to military command authorities.
– A medical examiner or organization investigating organ donation or transplantation.

We may also disclose your information under circumstances in which:
– You require emergency treatment, or if we are required by law to treat you but are unable to obtain written consent.
– We are ordered to do so by a court that is handling a lawsuit or other dispute.
– It is necessary to prevent serious threat to your health and safety, the health and safety of others, or the health and safety of the public.
– For workers compensation or similar program that provides benefits for work related injuries.
– We have removed any information that has the potential to identify you, so that the information is “de-identified”.
– We need to evaluate the performance of our staff in caring for you, or to educate our staff on how to improve the care provided to you.
– We need to remind you of appointments, to recommend possible treatment alternatives, or to inform you of health-related benefits and services that may be of interest to you.

Your rights as our patient:

– You have a right to inspect and obtain a copy of your health information, including medical and billing records, for as long as we maintain this information in our records.
– You have the right to correct your health information if you believe that the information is incorrect or incomplete.
– You have the right to receive an “accounting of disclosures”, that is, to whom we have disclosed your health information.
– You have the right to request that we further restrict the use or disclosure of your health information.
– You have the right to request that we communicate with you about your medical condition in a more confidential manner.
– You have the right to name a personal representative who may act on your behalf to control the privacy of your medical information.
– You have the right to request a copy of this notice.
– You have the right to request a copy of any revisions of this notice.
– You have the right to file a complaint if you believe your Privacy rights have been violated.

All requests must be in writing and sent to the attention of our office administrator. The practice has ten days to respond to a patient request for records, and thirty days to provide the patient with copies of their records. If we deny part or the entire request, we will provide you with a written notice that explains our reasons for doing so.

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)

Yes

Electronically emailed to my treating health professional(Required)

Yes

Used by health professionals for education and training(Required)

Yes

Used in paper or electronic health publications(Required)

Yes

Used in commercial broadcast(Required)

Yes

Used in internet or for marketing(Required)

Yes

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.

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.

Signed (Enter Name Here)(Required)