Patient Form Page Test

TEST FORM DO NOT USE

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 $650 is non refundable unless 48 hour written cancellation notice is provided.

Full Patient Form Page Based

Step 1 of 4

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 $650.00 – Initial consultation fee is non refundable unless 48 hour written cancellation notice is provided.

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 $650.00 consultation fee is not transferrable 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 $400.00. Any additional medical 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.

A 48-hour notice is required for cancellation otherwise patient is responsible for a $650 cancellation fee for new patients and $200 for existing patients. Payment is due when services are rendered and fees are non-refundable.

Patient Form Page Test

Full Patient Form Page Based

Pharmacy Info

Please Confirm all info

Questionnaire

For Women Only

Note

Doctor / Medical Contacts

Office Policy & Cancellations

Privacy Policy

Medical Photography Consent Form

Laboratory Informed Consent Form

Prescription Informed Consent Form