New Patient Form

First Name

Date of Birth

Preferred Language

Last Name

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Gender

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Race

Social Security Number

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Marital Status

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Ethnic Group

Street Address

City

Phone (Home)

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Employment

Name of Emergency Contact

State

Phone (Mobile)

Occupation

Relationship to Patient

Zip Code

Email

Emergency Contact Number

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Referred by

Medical History

Please list any current or past medical conditions including any surgeries

Please list any upcoming medical procedures including dental work.

Please indicate your key skin concerns and corresponding body area
Please indicate which, if any, cosmetic treatments you have done in the past. Be sure to include date of the last treatment and your level of satisfaction with results.

Please list your full PM skincare regimen.

Please list down all your allergies to medication.

Name of your primary physician.

Please list any medications, prescriptions or supplements you are currently taking.

Please provide current pharmacy address, phone number and fax number.

Phone number of your primary physician.

FINANCIAL/INSURANCE INFORMATION

Dr. Kline does not participate with any health insurance. I understand that I am responsible for all charges incurred and that payment is due at the time services are rendered. We require a copy of your insurance card for laboratory purposes only.

 

I request that payment of authorized Medicare benefits be made either to me or on my behalf to Mitchell Kline, M.D. for services furnished to me by the provider. I authorize any holder of medical information about me to release to CMS and its agents any information needed to be determine these benefits payable for related services.

Carrier Name

Group #

Employer Sponsored?

ID #

Relationship To Insured

Government Sponsored?

Insurance Billing Address

KINDLY GIVE 24HR HOURS NOTICE TO CANCEL APPOINTMENTS. A FEE OF $100.00 WILL BE BILLED TO YOU FOR LESS THAN 24HOUR HOURS NOTICE AS WELL AS FAILURE TO KEEP SCHEDULED APPOINTMENTS

PATIENT REQUEST FOR EMAIL COMMUNICATIONS

By signing this I agree to receive the following types of emails. Please check all that apply.

RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM

Are you the patient, parent or legal guardian of the patient?

Your Signature

Communications over the Internet and/or using the email system are not encrypted and may not be secure. There is no assurance of confidentiality when communicated via email. To request that this provider communicate with you via email you must complete this form.

 

Please be advised that:

 

  • This request applies only to the healthcare provider that you indicate below. If you would like to request to communicate via email with another health care provider or program, you must complete a separate request for that office.

  • DR. MITCHELL A. KLINE will not communicate health information that is specially protected under state and federal law (e.g., HIV/Aids, substance abuse, mental health information) via email.

  • Your request will not be effective until you receive and respond appropriately to a test email message.

Our Address

700 PARK AVE, NEW YORK, NY 10021

Email: info@drklinedermatology.com

Tel: 212-517-6555

Clinic location
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Office Hours

Monday: 8:00am – 5:00pm

Tuesday: 8:00am – 6:30pm

Wednesday: 9:00am – 12:00pm

Thursday: 8:00am – 5:00pm

Friday: 8:00am – 4:00pm

 

By Appointment Only

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