Patient Registration Form
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1
2
3Valley Dermatologic Medical Group
Simi Dermatologic Medical Center
18364 Clark Street
2925 Sycamore Drive #203
Tarzana, CA 91356
Simi Valley, CA 93065
818-345-7122
805-527-6586
Patient Registration Form
Today's Date
______________
Name: ________________________________________________
Date of Birth: ____/_______/_______
First
Middle
Last
Month
Day
Year
□ Married □ Single □ Divorced □ Widowed
Sex:
M
F Occupation: ________________________
Address:
_______________________________________________________________________________________________________
Street number
Apt/Unit #
_______________________________________________________________________________________________________
City
State
Zip
Where should statements of your account be sent if different from above?
_________________________________________________________________________________________
Home Phone: _______________________
Cell phone ___________________________
Work Phone: ________________________
Emergency Phone: _____________________
Would you like to receive Email from Valley Dermatology yes no: Email address _________________________________
In case of emergency, notify: Name ________________________________
Contact number __________________________
Social Security Number: ________________________________
Drivers License # _________________________
Employer: ____________________________________________________________________________________
Name/Address
Referred by: physician_________________________________________________________________
family/friend
Insurance
Yellow pages
internet
previous patient
INSURANCE INFORMATION:
Please present insurance cards and photo ID to the receptionist so copies may be made.
Primary insurance: □ Blue Cross
□ Blue Shield
□ PPO
□ Other □ None
Subscribers name:____________________ DOB:
_____ Relationship to insured:
□ self □ spouse □ child
Secondary Insurance □ Blue Cross
□ Blue Shield
□ PPO
□ Other □ None
Subscribers name:____________________ DOB:
_____ Relationship to insured:
□ self □ spouse □ child
Do we have your permission to:
Leave a message on your answering machine at home?
YES
NO
Leave a message at your place of employment?
YES
NO
Discuss your medical condition with any member of your household?
YES
NO
If yes, whom: ________________________________________ Relationship ________________________
OFFICE POLICIES:
All copayments, deductibles and non-covered services are due at the time of service.
All cosmetic procedures are to be paid at the time of service. These are not billed to the insurance.
It is the responsibility of the patient to understand their individual policy. Please be aware that co payment amounts
may not be applicable for any type of surgical service performed.
Appointments must be cancelled 24 hours in advance. All non-cancelled appointments may be subject to charge.
_______________________________________________________ ______________________________________________
Patient Signature
Date
OFFICE USE ONLY
Insurance cards scanned and copies
Initials __________
Rev: 8/19/2015
Verify form filled out completely and legible
Initials __________
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