El Segundo Dermatology

Patient Registration and Health Questionnaire

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Sex *


Preferred Number *
May we leave a detailed message? *
May we text appointment reminders? *

May we email appointment reminders? *
Would you like to be notified of promotions and events? *


CONSENT TO DISCUSS CARE. If you are 18 years or older we cannot discuss your care with other family members, spouses or caretakers without your consent. Do you authorize consent for any other individuals? *
If yes:



Past Medical History *
 
Skin Disease History *
 
History of Skin Cancer
 LocationYear
Basal Cell:
Melanoma:
Squamous cell:
Unknown:
Other:
Do you wear Sunscreen? *
 
Do you tan in a tanning salon? *
Do you have a family history of melanoma? *
 
Cigarette Smoking *
Do you have any of the following? *
Alerts *

Would you like information on any of the following: *

INSURANCE INFORMATION

ELIGIBILITY: Please be aware that your health insurance policy is a contract between you and your insurance company. It is an agreement that your insurance will pay for covered medical services as long as your premiums are paid. Because they may not pay for every service, you will be responsible for any non-covered charges. We will verify your eligibility before your visit but please keep in mind that a determination of benefits with your carrier is NOT a guarantee of payment.
 
DEDUCTIBLES: Before your visit, we will verify your deductible and/or co-pay amounts. If your annual deductible for
the calendar year has not been met, you will be responsible for any charges incurred during your visit, payable at the
time of service. We will also collect any co-pay amounts at the time of service.
 
OUTSIDE SERVICES: Please be aware that your care may require the use of laboratory or pathology evaluation. These studies are not performed at our practice so please understand that you will receive a separate bill from the pathologist or laboratory providing those services. If you have a preference for a specific facility, please notify us prior to any procedure so that we can do our best to accommodate you.
 
I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for the services provided. I also authorize El Segundo Dermatology or my insurance company to release any information required to process my claim.
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ACKNOWLEDGEMENT OF PRIVACY PRACTICES

I hereby acknowledge that I have received a copy of El Segundo Dermatology's Notice of Privacy Practices.
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CONSENT FOR TREATMENT

I understand that many dermatological conditions are chronic and require ongoing care. All medications have side effects and there are risks to any medication prescribed. Dermatologists frequently diagnose skin growths by
performing a skin biopsy and treat skin growths by freezing, cauterization, and/or cortisone injection.
I understand that there are risks to any procedure and that these risks include, but are not limited to:
 
-Temporary or permanent discoloration
-Scarring
-Pain 
-Infection
-Bleeding
-Nerve damage
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All information entered into this form is transmitted through a secure network directly to our office and becomes protected health information.