New Patient Form

 

 

 

Section I: Demographic Information

Section II: Medical History

Please check any of the following conditions you currently have or have had in the past:

Have you or any members of your family (specify who) had:

Section III: Social History

Section IV: Financial Policy

Pathology and Laboratory Fees:
Pathology and laboratory fees are separate from our fees and will be billed directly to you. You will receive a separate bill from the lab company.

CANCELLATION POLICY:

New Patients: Any cancellation within 48 business hours will result in loss of the deposit. If you need to reschedule your appointment, we require 24-hour notice. (Monday appointments require notification by noon on the previous Friday.) Please call the office so we can accommodate other patients.

Existing Patients: Any cancellation within 24 business hours will incur a $100 fee.

Special Procedures: Any procedure requiring a deposit (e.g., Fraxel, Sofwave) will forfeit the full deposit if cancelled within 48 business hours.

REFUNDS: We do not offer refunds on services rendered, regardless of outcome.


CREDIT CARD AUTHORIZATION POLICY

All patients must provide a valid credit or debit card to be kept securely on file before receiving care. The card will be used to cover outstanding patient responsibilities:

Authorization — By signing below, you authorize Madfes Dermatology & Aesthetics Group to charge your credit or debit card for any outstanding balances as described above.

If your card information changes, please notify our office immediately to avoid disruption in care or billing.

Patient Acknowledgment: I have read and understand the Credit Card Authorization Policy. I authorize Madfes Dermatology & Aesthetics Group to charge my credit or debit card for balances as outlined above.


I have read, understand, and agree to the financial policies of this office. I am fully responsible for all professional fees and services rendered.

Section V: HIPAA Consent

I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

Section VI: Photography Consent

I authorize my healthcare provider to take photographs or videos of me for the purpose of medical documentation, diagnosis, treatment planning, or education. I understand that these photographs or videos are part of my medical record and will be kept confidential in accordance with HIPAA regulations.

I understand that additional consent will be obtained if these images are to be used for purposes other than those listed above, such as marketing or publication.

Section VII: Learning Assessment

Please check how you prefer to learn new information (check all that apply):

Do you have any special needs that affect how you learn best?

If yes, please explain:

 

Section VIII: Universal Medication Form

Prescription and over-the-counter medications (examples: aspirin, antacids); herbals (examples: ginseng, ginkgo); and vitamins. Include medications taken as needed (example: nitroglycerin).

Date PrescribedMedication / DoseNotes: Reason for Taking

Section IX: Disclosure Information

In accordance with HIPAA guidelines, please list any individuals with whom we are allowed to discuss your medical information.

Section X: Review and Submit

Please review your form carefully before submitting. Ensure that all required fields are completed.

Submit Instructions: Your information will be transmitted securely via our HIPAA-compliant system.

I certify that I have read and filled out the patient registration and medical history form fully and correctly to the best of my knowledge, and that the information that I have supplied is complete and correct. I understand that withholding medical information could lead to complications or problems that may have been prevented if that information were known prior to my care and treatment. I acknowledge that I can obtain and will read information regarding the providers of care in this organization, DNR (Do Not Resuscitate), Patient’s Bill of Rights and Responsibilities, HIPAA regulations, and information regarding the grievance process.