562

South Fair Oaks Ave.

PASADENA, CA 91105
626-123-4567

PT ACCOUNT #:

PATIENT INFORMATION

LAST NAME:

FIRST NAME:

MI

ADDRESS:

APT :

CITY:

STATE:

ZIP:

SEX: (M) (F) EMPLOYER:

OCCUPATION:

WORK PHONE:

HOME PHONE:

CELLUAR:

EMAIL:

SIGN UP FOR MONTHLY NEWSLETTER/EMAIL BLAST YES

NO

BIRTHDATE:

AGE:

SS#

MARITAL STATUS:

RACE/ETHNICITY:

WHOM MAY WE THANK FOR REFERRING YOU TO US?

INSURANCE INFORMATION

INSURANCE CARRIER:

PHONE:

CLAIMS ADDRESS:

CITY:

STATE:

ZIP:

COPAY $

ID #:
GROUP#:
*IF YOU ARE NOT THE POLICYHOLDER, PLEASE PROVIDE THE FOLLOWING:

POLICYHOLDER NAME:

POLICYHOLDER DATE OF BIRTH:

POLICYHOLDER SSN#:

PATIENTS RELATIONSHIP TO POLICYHOLDER:

PATIENTS WHO ARE MINORS PRESENT WITHOUT A GUARDIAN
IF YOU ARE A MINOR, THE SKIN CENTER OF PASADENA REQUIRES WRITTEN AUTHORIZATION FROM A LEGAL GUARDIAN THAT
WE MAY CONDUCT A MEDICAL EXAM AND/OR TREATMENT WITHOUT THE PRESENCE OF A LEGAL GUARDIAN.
TO BE COMPLETED BY LEGAL GUARDIAN AND FAXED TO 626-793-9018
I AUTHORIZE

TO BE SEEN WITHOUT A LEGAL GUARDIAN PRESENT.

SIGNATURE:

RELATIONSHIP:

DAYTIME TELEPHONE:

DATE:

ACKNOWLEDGEMENT OF RECEIPT: I hereby acknowledge that I have received a copy of the The Skin Center
of Pasadena Notice of Privacy Practices (HIPPA).

Signature:

Date:

May we leave appointment confirmations and or confidential medical messages on your voicemail? Yes

No

Please note preferred phone number:


562 South Fair Oaks Ave.
PASADENA, CA 91105
626-123-4567

PT ACCOUNT #:

Financial Policy

Payment is expected as services are rendered. We accept cash, personal checks, Visa, MasterCard, and
American Express. Gratuity may not be added to credit card transactions.

For those patients who are covered by insurance, we will be happy to bill on your behalf, whenever
medically applicable, as long as we are a contracted provider with your insurance company. Any co-pays,
co-insurance, and/or deductibles as specified by your policy will be collected on the day of service.

Verification of benefits is not a guarantee of coverage. Medical necessity is up to the determination of
your insurance provider. You the patient may be responsible for services even if The Skin Center of
Pasadena is contracted with the patients insurance company.

If we are not a contracted provider, we will collect payment at the end of your visit, and provide a
statement for you to submit to your insurance company for direct reimbursement.

Any outstanding balance for which you are responsible is expected to be paid in full within 30 days of
notification.

Thank you,
The Skin Center of Pasadena

I understand that I will be expected to pay for all applicable fees the day of service.
I understand that I am responsible for any balances not covered by insurance.
I will assume responsibility for notifying this office of any changes in insurance coverage.

I authorize any insurance company providing me with medical insurance to pay directly to The Skin Center of
Pasadena the amount due in my pending claim for basic medical, major medical or surgical treatment (if applicable).

I authorize The Skin Center of Pasadena to release to any company providing me with medical insurance any
information, including the diagnosis and the records of all treatments and/or
examinations provided to me The Skin Center of Pasadena for the purpose of billing (if applicable).

I agree to this financial policy and I have read and received a copy of this document.

Signature

Date


562 South Fair Oaks Ave.
PASADENA, CA 91105
626-123-4567

PT ACCOUNT #:

Cancellation Policy
For all medical, laser, and cosmetic appointments, we have a 24-hour notification policy. Requests for
rescheduling or cancellations must be made with our office personnel 24 hours prior to the appointment
date in order to avoid a cancellation fee.

Short Notice (Less Than 24 Hours) Rescheduling Request/Cancellation Fees

Medical Appointments:

$ 50.00

Laser Appointments:

$ 50.00

Cosmetic Appointments:

$ 25.00

Aesthetic Appointments:

$ 25.00

I have read this policy and understand that I will be charged for short-notice rescheduling requests or
cancellations.

Signature:
Date:


562 South Fair Oaks Ave.
PASADENA, CA 91105
626-123-4567

PT ACCOUNT #:

TREATMENT INTERESTS

Name

Email Address

Date

Please check all conditions and treatments in which you might be interested.

Acne / Acne Scars or Marks

Age Spots / Brown Spots

Glycolic Peels / Chemical Peels

BOTOX

Facials / Microdermabrasion

Fillers (JUVEDERM, Perlane, Restylane, RADIESSE, Sculptra)

Hair Removal

Laser Treatments for Skin Rejuvenation / Skin Resurfacing

LATISSE (for longer, thicker, darker lashes)

Rosacea

Skin Care

Skin Tag Removal

Spider Veins / Leg Veins

Stretch Marks

Sun Damage

Texture Improvement

Wrinkle Elimination

Please list any other treatments you might be interested in:


562 South Fair Oaks Ave.
PASADENA, CA 91105
626-123-4567

PT ACCOUNT #:

Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use and disclose
protected health information about you. The Notice contains a Patient's Rights section
describing your rights under the law. You have the right to review our Notice before signing this
Consent.* The terms of our Notice may change. If we change our Notice, you may receive a
revised copy by contacting our office.
You have the right to request that we restrict how protected health information about you is
used or disclosed for treatment, payment, or health care operations. We are not required to
agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you agree to our use and disclosure of protected health information about
you for treatment, payment, and health care operations. You have the right to revoke this
Consent in writing, signed by you. However, such a revocation shall not affect any disclosures
we have already made in reliance on your prior Consent. The Practice provides this form to
comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The Patient understands that
Protected health information may be disclosed or used for treatment, payment, or
health care operations.
The Practice has a Notice of Privacy Practices, and that the Patient has the opportunity
to review this Notice.
The Practice reserves the right to change the Notice of Privacy Practices.
The Patient has the right to restrict the uses of the Patient's information, but the
Practice does not have to agree to those restrictions.
The Patient may revoke this Consent in writing at any time, and all future disclosures
will then cease.
The Practice may condition treatment upon the execution of this Consent.

Signature of Patient or Representative:

Relationship to Patient (if other than Patient):

Date:

* A detailed copy of our Notice of Privacy Practices is available at the Front Desk.