Get Rodgers Dermatology New Patient Information Sheet Patient Name: / / Last Name First Name Mi Name

Completing the Rodgers Dermatology New Patient Information Sheet is a vital step in initiating your care at our facility. This guide will walk you through each section of the form to ensure that you provide all the necessary information accurately and efficiently.

Follow the steps to effectively complete the patient information form.

1. Press the ‘Get Form’ button to access the document and open it in your chosen editor.
2. Begin by entering your full name in the designated fields for Last Name, First Name, and Middle Initial (MI). Ensure that the names are spelled correctly as they will be used for your medical records.
3. Input your date of birth using the provided format. If you are filling out this form for a minor, indicate the name of the parent or guardian responsible for the child next to the respective prompt.
4. Provide your complete address including street, city, state, and zip code. Double-check all information for accuracy, as this will be used for communication purposes.
5. Enter your contact phone number. You can select either Cell or Home by placing a checkmark in the relevant box. Also, provide your email address ensuring it is accurate for confirmation and updates.
6. Indicate any language you speak other than English, if applicable, and fill in any applicable race and ethnicity information as required.
7. If your insurance information differs from your personal details, fill in the name of the insured and their date of birth. Then, provide the primary insurance company name, identification number, and group number.
8. Complete the secondary insurance information in the same manner, if relevant.
9. Fill in the name of your referring physician, if applicable, and note any family members that have been treated at this dermatology office.
10. Answer the questions about your interest in cosmetic procedures and whether you wish to be contacted regarding cosmetic specials. Your responses can be marked with a ‘Yes’ or ‘No’ check.
11. In the authorization section, read carefully through the stipulations and check the box for consent if you agree to the terms presented.
12. Finally, provide your signature and the date. If you are a minor, include the signature of the parent or guardian.
13. After filling out the form, be sure to save your changes using the options available in your editor for downloading, printing, or sharing the document.

Complete the online document now to ensure a smooth and informative visit to Rodgers Dermatology.