New Patient Form Gender Male Female No Answer Race Caucasian American Indian Alaska Native Asian Black / African American Pasific Islander Other Marital Status Married Single Divorced Widowed Ethnic Group Hispanic or Latino Not Hispanic or Latino Unknown Employment Employed / full time Employed / part time Not Employed / Looking for work Not Employed / Not looking for work Retired Self Employed Homemaker Student Prefer not to answer Name of Emergency Contact Referred by Physician Patient Friend 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.
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. I certify the email address provided on this request is accurate, and that I accept full responsibility for messages sent to or from this address. I have received a copy of the IMPORTANT INFORMATION ABOUT PATIENT EMAIL form, and I have read and understand it. I understand and acknowledge that communications over the Internet and/or using the email system are not encrypted and may not be secure: that there is no assurance of confidentiality of information when communicated this way. I understand that all communications in which I engage may be forwarded to other providers for purposes of providing treatment to me. I agree to hold DR. MITCHELL A. KLINE and individuals associated with him harmless from any and all claims and liabilities arising from or elated to this request to communicate via email. Pre and post care instructions related to in-office treatments. Appointment reminders and related follow up communications. New service information, skincare and practice specials relevant to Kline Dermatology. RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM
Are you the patient, parent or legal guardian of the patient?