Patient Registration Form

Please complete and sign all applicable fields/forms and submit at least 48 hours prior to your first visit.  Thank you!

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  • Patient Information

  • Date Format: MM slash DD slash YYYY
  • ^ Requested under federal guidelines for "Meaningful Use" to optimize patient-specific treatment and counseling.

  • Other Information

  • Did a doctor refer you to us?

  • Responsible Party

    (complete only if the patient is a minor/dependent)
  • Date Format: MM slash DD slash YYYY
  • *We do not bill absent parents; the adult presenting the patient for care is the responsible party.

  • Insurance

  • Primary Insurance
  • Date Format: MM slash DD slash YYYY
  • Secondary Insurance
  • Date Format: MM slash DD slash YYYY

  • Signature of Patient/Responsible Party

  • Signature of Patient/Responsible Party
  • Date Format: MM slash DD slash YYYY

  • PATIENT FINANCIAL POLICY

  • Financial Policy You are responsible for any and all charges that your insurance company does not cover. All out-of-pocket costs, including high deductibles, co-pays, co-insurances, and non-covered/cosmetic fees, will be collected at the time of service. If your claim is denied, you will be billed and payment is due in full upon receipt of the bill. Please check with your insurance company or our reception staff prior to your appointment if you have any questions regarding your insurance coverage or treatment costs.

    Insurance Participation This practice has contracts with Medicare and with many managed care plans. As a courtesy to our patients, if we have a contract with your plan, we will file a claim with your insurance company upon receipt of a current insurance card. In addition, we will file secondary insurance for Medicare patients only.

    If you do not have one of the plans with which the practice is contracted, the total cost of your visit is due at the time of service. To assist you in obtaining reimbursement for covered charges, we will provide you with an itemized statement, which you may then submit directly to your insurance carrier.

    Referral Requirements For HMO and POS participants, in order for your insurance company to pay for your visit, it is your responsibility to obtain a referral from your primary care physician prior to each visit with us. If a referral is not obtained and your claim is denied, you will be responsible for the full balance upon receipt of the bill.

    Payment Options For your convenience in paying, this office accepts Discover, Master Card and Visa, in addition to cash and checks. There is a $25.00 charge for returned checks. If two checks are returned, you will no longer be able to write checks to our office.

    If you fail to meet your financial obligation to Dermatology Center of Loudoun, PLC and it becomes necessary to take action to collect on your account, you agree to pay for any and all costs and expenses incurred in the collection of your account, including attorney and collection agency fees.

    No-Show Policy Because we make every effort to see patients on time, we do not overbook to accommodate patients who do not keep their appointments. Therefore, the practice charges $25.00 for missed office visit appointments and $50.00 for missed surgery appointments not canceled with at least one business days’ notice. Insurance will not pay for these charges.

    * I understand and agree that I am ultimately responsible for the balance on my account for any professional services rendered.
    * I certify that I have read and understood the financial policy of Dermatology Center of Loudoun, PLC and agree to fully abide by the policy.
    * Do not sign this form unless you positively understand the consequences of your visit and the charges you may encounter.

  • Date Format: MM slash DD slash YYYY
  • Signature of Patient/Responsible Party

  • CONSENT TO TREATMENT

  • I, the undersigned, hereby consent to dermatologic evaluation to determine the best treatment course. After discussion with physician and acceptance of treatment(s), I authorize the administration and performance of medically necessary treatment(s); the administration of any needed anesthetics; the performance of any procedures as may be deemed medically necessary or advisable; the use of prescribed medications; the performance of diagnostic procedures; the taking and utilization of cultures and performance of other medically accepted laboratory tests, all of which, in the judgment of the physician, are considered medically necessary or advisable. I also reserve the right to refuse treatment at any time during the evaluation and take full responsibility, holding the physician harmless, for refusing recommended treatment.
  • Date Format: MM slash DD slash YYYY
  • Signature of Patient/Responsible Party

  • PATHOLOGY CONSENT

  • I, the undersigned, understand that any and all tissue removed from my skin as part of a medically necessary or a cosmetic treatment will be sent for dermatopathology for tissue evaluation and diagnosis. All charges related to the skin samples sent for dermatopathology incur a separate fee from the procedure or treatment. The fee may or may not be covered by your insurance. Any costs related to this service are patient responsibility.
  • Date Format: MM slash DD slash YYYY
  • Signature of Patient/Responsible Party

  • ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

  • Thank you for choosing Dermatology Center of Loudoun, PLC for your healthcare needs.

    We are required by law to provide you with a copy of our Notice of Privacy Practices. To ensure that our records are accurate, please sign this form to acknowledge that you have been provided with a copy of our Notice of Privacy Practices.

    Dermatology Center of Loudoun Lansdowne VA | Ashburn VA Notice Of Privacy Practices
  • Date Format: MM slash DD slash YYYY
  • Signature of Patient/Responsible Party

  • INSURANCE AUTHORIZATION

    Signature of Patient/Responsible Party

  • For ALL INSURANCES except Medicare:

    I certify the information I have provided with regard to my insurance coverage is true and correct. I authorize my insurance company to pay benefits on my behalf directly to Dermatology Center of Loudoun, PLC. I authorize Dermatology Center of Loudoun, PLC or any holder of medical or other information about me to provide to my insurance company any information necessary to process claims for services rendered to me. I permit a copy of this authorization to be used in place of the original.

  • Signature of Patient/Responsible Party
  • Date Format: MM slash DD slash YYYY

  • If you have MEDICARE:

    I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply.

  • Signature as it appears on Medicare Card
  • Date Format: MM slash DD slash YYYY

  • If you have MEDIGAP:

    If you have a supplemental policy and it is a MEDIGAP policy to which your Medicare Carrier automatically “crosses over”, we are required to keep a separate signature on file:

    I request authorized MEDIGAP benefits be made on my behalf for any services furnished to me. I authorize any holder of medical information to release to my MEDIGAP carrier any information needed to determine these benefits or the benefits payable for related services.

  • Signature as it appears on MEDIGAP Card
  • Date Format: MM slash DD slash YYYY

  • PATIENT MEDICAL HISTORY FORM

  • This form is a part of your permanent medical record. Thank you for taking the time to complete it as thoroughly and accurately as possible.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Please indicate if you would like to discuss treatment options for the following:
  • Please list all current medications, including topical creams, vitamins, OTC’s, and herbal supplements:
  • Please list all current medical conditions:

  • Date Format: MM slash DD slash YYYY
  • Please list any known drug allergies:

  • FAMILY HISTORY

    Please list any medical conditions (including but not limited to skin conditions, such as non-melanoma and melanoma skin cancers, psoriasis, eczema) of the following family members:


  • SOCIAL HISTORY

    Please be honest. This can affect medication selection and dosing.


  • REVIEW OF SYMPTOMS

    Please check any of the following that you have experienced in the past 6 months:


  • I hereby certify the above information to be true and correct to the best of my knowledge.
  • Signature of Patient/Responsible Party
  • Date Format: MM slash DD slash YYYY
“Just wanted to compliment the office on the professionalism… Each time I have come in, its’s been a great experience; doesn’t even feel like I’m going to a doctor’s office. Thank you so much! And, this is why I recommend your office more than others. It’s the quality of care!”

– George King
“Sofia’s radiant smile shows a person that loves her profession. She makes me happy when I see her and she is helping me get better. I trust her completely to make any decisions regarding my treatment because she is knowledgeable, competent and most important – caring”.

– Barbara O., psoriasis

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