Minor 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
Minor Patient Registration Form
Today's Date __________________
Child's Name: __________________________________________
Date of Birth: ____/_______/_______
First
Middle
Last
Month
Day
Year
Sex:
M
F
If Student:
Full Time
Part Time Name of School: _____________________________________________
Home Address: ________________________________________________________________________________________
Street#
Street Name
Apt#
______________________________________________________________________________________________________
City
State
Zip
Legal Guardian/Parent Name: ______________________________________
D.O.B.:_____/_______/_______
First
Middle
Last
Month
Day
Year
Where should statements of this account be sent if different from above?
_________________________________________________________________________________________
Home Phone: ____________________Cell phone __________________Work Phone: ___________Emergency Phone: ______________
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.
Social Security Number: ______________________
Drivers License __________________________
Primary insurance: □ Blue Cross
□ Blue Shield
□ PPO
□ Other
□ None
Relationship: □
Subscribers name:__________________________ DOB:__________ __
Mother □ Father □ Other
Secondary Insurance □ Blue Cross
□ Blue Shield
□ PPO
□ Other
□ None
Relationship: □
Subscribers name:__________________________ DOB:__________ __
Mother □ Father □ Other
Do we have permission to:
Leave a message on your answering machine at home?
YES
NO
Discuss your medical condition with any other member of your household?
YES
NO
If yes, whom: ______________________________ Relationship ________________________
Many times parents find themselves unable to accompany their teen or young adult children to appointments. This statement has been
prepared for your convenience should you at some time be unable to accompany your child.
I hereby grant Valley Dermatology permission to treat my child when they arrive at the office unaccompanied.
Parent/Legal guardian signature_______________________________________
Date ________________________
OFFICE POLICIES:
The adult bringing the minor patient in will be responsible for all copayments, deductibles and non-covered services that 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 adult that is bringing the minor patient in 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.
____________________________________
_________________________________
Parent / Legal Guardian Signature
Date
OFFICE USE ONLY
Insurance cards scanned and copies
Initials __________
Rev: 8/20/2015
Verify form filled out completely and legible
Initials __________
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