Garrott Dermatology

Patient Info

Last Name:

First Name:

M.I.:

Street Address:

City:

State:

ZIP:

Home Phone

Work Phone

Social Sec. #:

Date of Birth:

Age:

Sex:

Married?

Patient's Employer:

Patient’s Occupation:

Employer's Address:

Employer’s Phone:

Full Time? Part Time? Retired? Student? Name of School:

Spouse’s Info

Spouse's Last Name:

First Name:

M.I.:

Street Address:

Social Sec. #:

Date of Birth:

Sex:

Responsible Party

Social Security Number:

Relationship to Client:

D.O.B.:

Employer:

Phone:

Employer Address:

City:

State:

ZIP:

Home Phone

Work Phone

Social Sec. #:

Date of Birth:

Sex:

Nearest Relative (not living with you)

Phone #:

Insurance Information

Primary Insurance
Primary Insurance Name:
Insurance Address
Name of Insured
Insured's ID#:
Group #:
Employer Name:
Employer Address:
Employer Phone:
Relationship of Patient to Insured:
Secondary Insurance

Secondary Insurance Name:
Insurance Address
Name of Insured
Insureds ID#:
Group #:
Employer Name:
Employer Address:
Employer Phone:
Relationship of Patient to Insured:

Additional Information

Other Family Members that are Patients:
Pharmacy of Choice:		Phone:
In case of Emergency, who should be Notified?		Phone:
Referred by:
Primary Care Physician:


Authorization and Payment

In order to establish optimal relations with our patients and avoid misunderstanding regarding our payment policies, our staff is trained to inform you of the financial policies of this office. PAYMENT IS EXPECTED FROM YOU, AT THE TIME SERVICES ARE RENDERED, FOR “YOUR PART” OF THE CHARGES. WE ACCEPT VISA AND MASTERCARD FOR YOUR CONVENIENCE. It is your responsibility to pay any balance not paid by your insurance. In the event the account is turned over for collection, the collection and/or legal fees, including attorney fees, shall be your responsibility. Your signature below indicates that you understand and accept this herein and authorize payment of medical benefits to the Doctor when assigned claim is filed.
Patient or Responsible Party Initials as Proof of Signature:		Date:
PLEASE PRESENT INSURANCE CARDS AND PHOTO ID TO THE RECEPTIONIST SO COPIES MAY BE MADE.
Do we have permission to leave a message on your:
Answering machine? Place of employment? Fax machine? E-mail?
If yes, fax #: E-mail:
Do we have permission to discuss your medical condition with any member of your household? Yes No If yes, whom? Relationship:

Attention: Please be advised that Garrott Dermatology uses Biloxi Regional for cultures and biopsies. If your insurance does not cover Biloxi Regional, please indicate the lab or hospital to where you would like the specimens sent: All services done by any hospital or lab are billed separately and it is the patient’s responsibility for payment.
Initials:		Date: