Grafton Dermatology & Cosmetic Surgery

Patient Information

* = Required Fields

Last:*

First:*

Initial:

Appointment Date :

Mailing Address:*

City:*

State:*

Zip:*

You must submit at least one phone number*

Home Phone:	Work Phone:		Cell Phone:
DOB:*	Age:*	Sex:*	Marital Status:*	SS#:*

PARENT OR RESPONSIBLE PARTY (If different from patient)

Last:

First:

Initial:

Mailing Address:

City:

State:

Zip:

Home Phone:	Work Phone:		Cell Phone:
DOB:	Age:	Sex:	Marital Status	SS#

INSURANCE INFORMATION (Please present insurance card at time of check in.)

Primary Insurance Name:*

Ins. Address:

Name of Insured:*

Insured's date of birth*

Insured's SS#*

Insured's ID#*

Group#*

Employer Name

Employer Address

Employer Phone (Area Code)

Relationship of patient to the Insured*

Secondary Insurance Name:

Ins. Address:

Name of Insured:

Insured's date of birth

Insured's SS#

Insured's ID#

Group#

Employer Name

Employer Address

Employer Phone (Area Code)

Relationship of patient to the Insured

Other family members that are patients:
Pharmacy of choice:	Phone:
In case of Emergency, who should be notified? *	Phone:*
Referred by:
Primary Care Physician: *
I authorize the release of medical information to my primary care or referring physician, to consultants if needed and as necessary to process insurance claims, insurance applications and prescriptions. I also authorize payment of medical benefits to the physician.
Patient or Responsible Party Signature *	Date*

In order to establish optimal relations with our patients and avoid misunderstanding and confusion regarding our payment policies, our staff is trained to consistently inform you of the financial payment policies of this office. Payment is required for all services at the time they are rendered unless you are in a prepaid plan in which we participate. For those patients, applicable copayments and deductibles will be collected. We accept payment in the form of cash, check, or credit card. In the event of hospitalization or major procedures, our office may file with the appropriate insurance. However, before such claims are filed, coverage will be preverified and you will be asked to pay any unmet deductible, non-covered services and copayments. In the event that your account must be turned over to collections, a $10.00 collection fee will be added to your account. Your signature below signifies your understanding and willingness to comply with this policy.

Patient or Responsible Party Signature*

Date*

Verify Insurance Company's Phone Number: