Follow the steps to successfully complete the form.

1. Click 'Get Form' button to obtain the form and open it in the online editor.
2. Begin filling in the patient information section. Enter today’s date, your preferred gender as Male or Female, and your full name including last name, first name, and middle initial.
3. Complete your home address by entering the street address, city, state, and zip code. Then, provide your home phone number, daytime phone number, and cell phone number.
4. Fill in your social security number, date of birth, and marital status by circling Single, Married, Divorced, or Widowed.
5. Identify your employer by entering their name and position. Then, provide the employer's address, including city, state, and zip code.
6. Record the names of your primary care physician and referring physician.
7. Input information for an emergency contact person, including their name, home phone, work phone, cell phone, and relationship to you.
8. Indicate whether DermSurgery Associates can contact you via email by selecting Yes or No.
9. Sign the form to authorize the use of your information and to ensure direct payment to Derm Surgery Associates from your insurance company.
10. Complete the primary insurance information section by entering the primary insurance company's name, phone number, policy holder's name, date of birth, and social security number. Include policy and group numbers.
11. If applicable, fill in the secondary insurance information similarly by providing the relevant details.
12. Review the entire form for accuracy and completeness before saving changes, downloading, printing, or sharing the form.

Begin filling out your patient information form online today to ensure a smooth visit.