The Derm Institute

Patient Demographics

Preferred Name

First Name

MI

Last Name

Age

Date of Birth

Contact Information

Email Address

Phone

Text Message OK?

Yes No

Street Address

City

State

Zip

Employment

Employer (Optional)

Occupation (Optional)

Emergency Contact

First Name

Last Name

Relationship to patient

Phone

Financially Responsible Party

Check here if you are the financially responsible party Check here if you are not the financially responsible party

First Name

Last Name

Relationship to patient

Date of Birth

Street Address

City

State

Zip

Phone

Primary Physician (Optional)

Physician Name

Phone

City

State

Preferred Pharmacy

Pharmacy Name

Pharmacy Phone

Street Address

City

State

Referral

How did you hear about us? (Select primary source)

Please specify

Reason for Today's Consultation

I understand that there are risks to any procedure, including, but are not limited to:

Bleeding
Pain
Infection
Scar
Discoloration (temporary or permanent)
Rarely, nerve damage

I also understand the following:

Total body examinations for skin cancer screening are performed if specifically scheduled in advance, as this may require additional time.
I understand that most clinic visits are scheduled for consultation of a specific skin condition. Procedures, even minor removals, usually need to be scheduled at a separate time. The Derm Institute will try to accommodate procedures if time permits.
I am aware that there are potential risks to any treatment or medication (oral or topical) prescribed. Dermatological conditions are often chronic in nature and may require ongoing care and for me to schedule follow up appointments.

I consent to having these procedures done as part of my evaluation and treatment.

Payment is required for all services at the time they are rendered. The Derm Institute is not currently accepting any commercial insurance plans. Any consultations for medical or cosmetic issues will have an associated consultation fee collected at the time of your visit. An itemized receipt can be made available at your request.

Applicable payments for medical consultations and procedures performed at The Derm Institute will be an out-of-pocket expense and considered out-of-network. Additional tests, i.e. pathology, laboratory, radiologic or other diagnostic tests may be billed separately in addition to the visit.

For your convenience, we accept cash, Visa, MasterCard, American Express, and Discover. CareCredit financing may be used subject to a minimum balance. At your request, a copy of this document can be made available to you.

Regardless of whether you have insurance, THE PATIENT IS ULTIMATELY RESPONSIBLE FOR PAYING for the services rendered. This contract is between you, the patient, and Annie Chiu, MD, Inc. Claims that you want submitted for any out-of-network benefits will be the responsibility of the patient. A copy of your Health Insurance Claim Form can be made available at your request.

Unless a payment plan has been arranged, all unpaid balances over 30 days will be turned over to a collection agency. You will be responsible for all collection costs, including court/attorney fees, and a 30% collection fee.

Cancellation Policy*

We require a minimum of 72-hour notice for appointment cancellation. A credit card will be needed to hold your appointment slot and you will NOT be charged if you provide us 72 hour notice of any appointment changes. Cancellations, rescheduling, or no-shows to your appointment during the 72-hour window will result in a fee of $250 for the first and second cancellation and $500 for subsequent cancellations which will be charged to the credit card on file.

*Cancellation Fee subject to change without notice

Your information has been sent. We look forward to seeing you at your appointment.

STEP 1: Patient information

Patient Demographics

Contact Information

Employment

Emergency Contact

Financially Responsible Party

Primary Physician (Optional)

Preferred Pharmacy

Referral

Reason for Today's Consultation

Patient Medical History (Check all that apply)

Past Medical History

Other

Other Health Conditions (Optional)

Past Surgeries (Optional)

Skin Condition History (Please check all that apply)

Key Past Medical History

Cautions (Check all that apply)

Allergies

Medication or latex allergies:

Medications

Prescription medications:

Over-the-counter medications:

Social History (Please check all that apply)

Cancellation Policy*