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Integrative Dermatology and Laser Spa
New Patient Form
Email address *
Full Legal Name *
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Date of Birth *
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Home Address *
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Ethnicity
Email Address
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Primary Care Physician
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Guarantor Info (Fill out if patient is not primary on Insurance) Name, Address, D.O.B, Relationship to patient
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Emergency Contact Info- Name, Phone #, Relationship to patient *
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Reason for Your Visit today? *
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What makes your condition better or worse?
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AUTHORIZATION TO RELEASE MEDICAL INFORMATION & ASSIGNMENT OF INSURANCE BENEFIT I authorize the release of any medical information necessary to process my insurance claim(s) and assign all medical and/or surgical benefits including major medical benefits, FWIM & VeerulaMD,LLC & Vindhya Veerula, M.D. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered valid as an original. Even though I have provided all of my insurance information, I understand that I may be financially responsible for any balance not covered by my insurance. I agree to provide my most current insurance information and if any bills are not paid by insurance because of outdated or inaccurate information, I agree to pay my entire bill in full – even though the bill might have been paid by insurance had I provided the correct information. I understand that holistic treatments are not a substitute for medical diagnosis and treatment, and no medical claims are made regarding these treatments. Please initial and date *
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FINANCIAL AGREEMENT Integrative Dermatology & VeerulaMD,LLC’s account balances are due at the time of service. I understand and agree that, (regardless of insurance coverage), I am ultimately responsible for any professional service rendered. I certifiy that this information is true & correct to my best knowledge. I will notify you of any changes in my insurance coverage, address, or health status. I accept this statement as notice from you that my insurance plan may not pay for any service that you provide to me because the service or procedure may not be covered by the plan or may not be considered medically necessary by the plan. I agree that all services and procedures that I receive from you have been requested by me with full knowledge that my insurance plan may not cover them. Please Initial *
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