Patient Registration Form

Instructions: this form can be completed on your computer.
At the end of the form, you can click "Submit" to send it to our office. Please click on
our General Office Policies section for important new patient information.

Patient Information
First and Last Name:
(*as it appears on your insurance card)
Address:
City:
State:
Zip Code:
Home Telephone Number
(*area code first)
Work Telephone Number
(*area code first)
Email address:
Prior name:
Date of Birth:
Marital Status:
Single Married Divorced Widowed
Sex:
Male Female
Employment Status:
Employed Part-time Student Full-time Student Other
REsponsible Person (if applicable)
Name:
Date of Birth:
Relationship to Patient:
Address:
City:
State:
Zip Code:
Home Telephone Number
(*area code first)
Occupation:
Employer:
Employer phone :
Employment Information
Patient Occupation:
Patient Employer:
Patient Employer Address:
City:
State:
Zip Code:
In Case of Emergency (not at home of patient)
Name:
Address:
City:
State:
Zip Code:
Home Telephone Number
(*area code first)
Relationship to Patient:
Primary Insurance Information
Name of Insured:
Insurance Company :
Date of Birth :
Relationship to Patient:
(*leave blank if not applicable)
Insured ID # :
Group # :
Secondary Insurance Information
Name of Insured:
Insurance Company :
Date of Birth :
Relationship to Patient:
(*leave blank if not applicable)
Insured ID # :
Group # :
How were you referred to our office?
By a Doctor
By a Patient
By a Seminar
Advertisement
Other
What is the name of your referral source?
Are you interested in Cosmetic Dermatology information?
Botox
Dermal Fillers
Skin Care Programs
Chemical Peels
Brown Spot Removal
Spider Vein Treatment
Laser Hair Removal
Laser Skin Rejuvenation
Would you like us to schedule a cosmetic consultation? Yes No

Comments or questions:

Do you give our office permission to discuss medical/financial information with another party?

Yes No       If yes, please provide their names and phone numbers below:
Name #1:
Relationship to Patient #1:
Telephone (day) #1:
Telephone (evening) #1:

Name #2:
Relationship to Patient #2:
Telephone (day) #2:
Telephone (evening) #2:
Consent to Treatment

I voluntarily consent to receive medical, health care and/or cosmetic services that may include diagnostic procedures, examinations and treatment.

Financial Responsibility and Assignment of Benefits

I have been provided with a copy of Ironwood Dermatology's financial policies. I agree to pay all charges for medical and health care services not covered by my insurance company.

Please enter your name in this box agreeing you understand the above term:

PLEASE NOTE
When you click on “Submit,” your form will be forwarded to our practice. If your computer’s security is set high, or you have certain pop-up blockers, or anti-spyware, you might get this same screen again instead of a screen acknowledging that the form has been submitted. Your form has been sent, however. If you have any question about your form getting to us, please call us at (520) 618-1630.