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.

Patient Agreements * I agree to pay all laboratory fees sent from this office, including pathology reports which are not covered by my insurance plan or if I …

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