*Please fill out this form completely

Patients Name (Last, first, middle initial) Patient Address Email Address Patient Marital Status: Single Married Other Employer Address Spouse or Parents Name Employed YN Student Full P/T City City

Birth date

Sex MF State Zip

Social Security # Home Phone

Employer State Employer Zip

Occupation Business Phone Business Phone

In case of emergency, notify: ____________________________ Phone #: ____________________ Relationship: _________________

Primary Dr. __________________________________________________ Phone #: (________)_____________________________

(Full Name)

Release of Medical Information to:

I, _____________________________________, authorize Valley Dermatology and Skin Cancer Center to release my medical and billing (Print Name) information to _________________________________ or leave a message at ( (Family Member) optional )___________________. (Phone Number)

Please read and sign: All professional services rendered are charged to the patient. Payment in full is due at the time of service. Cosmetic services are NOT covered by medical insurance and will not be billed to a secondary party. The patient is responsible for all fees, regardless of insurance coverage. This authorization remains valid and effective from the date of signing until revoked in writing. I understand that I may request a copy of this authorization. I have read this authorization and understand it. I understand I am financially responsible to said Valley Dermatology and Skin Cancer Center for the charges owed. I further agree in the event of non-payment to bear the cost of collection, and/or court cost and reasonable legal fees should this be required. Patient or Guardians Signature _______________________________________________________________________ Date _________/_________/_________