Patient demographic
Name, Contact Information, Emergency Contact, Referred By and Insurance.
health history
Past medical condition, Medications, Allergies, Surgical History and Family History.
payment for services
We accept cash, checks, Visa, MasterCard, American Express, Discover and Cosmetic Protect.
photography release
Permission to take photographs, slides, and/or videotapes for marketing purposes.
privacy practices
Patient Rights regarding protected health information (HIPPA).
hippa
Notice of Privacy Practices – Health Insurance Portability and Accountability Act (HIPAA).
managed care
Patients participating with an HMO must provide a referral or authorization number.
disability disclosure
Our office completes all disability forms and other miscellaneous paperwork at no cost.
record release
You may use this form to inspect, copy or request information maintained about you.