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dermatology
Cosmetic Surgery
Minimally-Intrusive Procedures
Skincare

Patient Registration

Patient Registration  |  Request Consultation  |  Pre-Op Questionnaire
Download PDF Forms
Prior to your visit, we strongly recommend that you check with your insurance company regarding deductibles and co-payments.

New Patients: Please use this form to register with Mid Valley Dermatology after you have scheduled an appointment with us. Note that all of the patient information we collect is for use within our office only and is protected against unauthorized access. This form uses secure SSL encryption.

NOTE: Please visit our Forms page to download a PDF version of this and other forms. These forms may be printed from your computer so you can fill them out at your convenience and bring them to our office at your next appointment.

Bold text shows required information. Text in green shows formatting examples or other special instructions.

This form uses SSL encryption.

Patient Information
Last Name  First Name
Middle initial Date of Birth [mm/dd/yyyy]
Address
Age
City Sex
State  ZIP Code 
Social Security Number [123-45-6789] Marital Status  
Driver's License # Home Phone
Email Address
Employer Work Phone
Occupation Spouses Name
Referred by (name) Referred by (address)
 
In Case of Emergency Contact:
 
Name Phone
Relationship to Patient
Person Financially Responsible
COMPLETE ONLY IF DIFFERENT FROM PATIENT
Last Name First Name
Middle Initial Social Security Number
[123-45-6789]
Address
Date of Birth
[mm/dd/yyyy]
City Home Phone
Email Address
State Occupation
ZIP Code Employer
Drivers License Number Work Phone
Insurance Information
NOTE: These are REQUIRED FIELDS! Please enter "NA" if you are a cash patient or if the fields do not apply to you.
Medicare No
Yes - Number: 		Medical No
Yes - Number:
Insurance Company Name Insurance Company Address
Subscriber Date of Birth
Social Security Number
[123-45-6789]
Group # Policy #
Subscriber Name (if not patient) Relationship to Patient
 
Payment is expected at the time of service. For individuals with Medicare or PPO's with whom our office is contracted, please see below:

Assignment of Insurance Benefits
I hereby authorize and request my insurance company to pay directly to the Doctor the amount due on my claim for services rendered to me or my dependent. I further agree that should the amount be insufficient to cover the entire medical and surgical expense, I will be responsible for payment of the difference; and if the nature of the condition be such that it is not covered by the policy, I will be responsible to the Doctor for payment of the entire bill. If it should be necessary to initiate legal proceedings to collect any unpaid amount, I will be responsible for all collection fees plus all interest charges.
I have read and acknowledged the above


If you have any questions regarding this form or the questions, please call (818) 907-7546 and speak with one of our registration specialists. Our office is open Monday through Friday from 8:15 am to 5:30 pm.

This form uses SSL encryption.