New Patient Registration
Welcome to Sunnycoast Dermatology

Step 1 of 4

Patient Information

Patient Registration — please present insurance cards & photo I.D. to the receptionist so copies may be made when you arrive.

Financial Policy

Our staff is trained to inform you of the financial policies of this office. PAYMENT IS EXPECTED FROM YOU AT TIME OF SERVICE, for "YOUR PART" of the charges. We accept CASH, CHECK, VISA & MASTERCARD. Your signature below indicates that you understand and accept this policy. Further, your signature authorizes the Doctor to release such medical information necessary to process your insurance claim (if any). You herein authorize payment of medical benefits to SUNNYCOAST DERMATOLOGY INC. when a claim is filed. If your account must be turned over for collections, a collection fee will be added to your account.

Date

First Name

Middle Name

Last Name

Gender

Current Age

Date of Birth

Contact Information

Local Address

Is your local address the same as your permanent address?

Permanent Phone

Local Phone

May we leave a phone message with personal medical information?

Emergency Contact Information

Marital Status

Emergency Contact (other than spouse)

Relationship to Patient

Contact Phone number

May we discuss your medical condition with any members of your family?

Employment Information

Are you employed?

Financial Policy Agreement

Signature of Patient or Guardian

Date

If Signed by Guardian, your relationship

Patient Relationship to Policy Holder

Who referred you to this office?

Prefer to fill this out by hand? Download a blank copy to print and bring with you.

Download the blank New Patient Packet (PDF)

New Patient RegistrationWelcome to Sunnycoast Dermatology

Patient Information

Financial Policy

New Patient Registration
Welcome to Sunnycoast Dermatology