Patient Registration - Derm Miami

Patient Registration Patient Name: _____Sex:_____ #: _____ Date of Birth: _____/_____/_____ Age: _____ Marital Status: S M D W Address: _____ Apt #: _____ City: _____ State: _____ Zip Code: _____ Home Phone: _____ Cell Phone: _____Work Phone: _____ Email: _____ Spouse Name: _____ Phone: _____ If Pt s under 18, Name of Parent or Legal Guardian: _____ Primary Care Physician: _____ Phone: _____ Referring Physician: _____ Phone: _____ INSURANCE INFORMATION Primary Insurance Member ID: _____ Insured Name: _____ Date of Birth: _____ Relation to Pt: _____ Secondary Insurance Co. _____ Member ID: _____ Insured Name: _____ Date of Birth: _____ Relation to Pt: _____ INSURANCE RELEASE AND ASSIGMENT (ALL patients ) I hereby authorize Dr.

Appointment Cancellation/No Show Policy The policy of this office is to encourage patients to give us notice of cancellation of any appointment within at least 24 hours before the end of the day prior to the scheduled

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  Policy, Patients, Registration, Appointment, Cancellation, Show, Patient registration, Appointment cancellation, No show policy

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