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Patient Information

Step one - Please call 479-443-5100 to make an appointment.
Step two - Complete registration form after an appointment has already been scheduled.
NOTE* - You can download/print a copy of the Patient Information Form HERE.

Today's Date

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Last Name(*)

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First Name(*)

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M.I.(*)

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Mailing Address

Street or PO Box(*)

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City(*)

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State(*)

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Zip Code(*)

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If different from mailing address

Street Address

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Phone

Cell

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Work

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Home

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Date of Birth

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Age

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SSN

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Sex

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Marital Status

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Spouse's Name

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Place of employment

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Emergency contact name and number

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Primary Care Physician

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Did this physician refer you?

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How did you hear about us?

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Responsible Party
(If different than patient)

Last Name

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First Name

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M.I.

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Mailing Address

Street or Box

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City

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State

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Zip Code

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Phone

Home

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Work

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Cell

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Relationship to patient

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SSN

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Employer

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DOB

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Insurance Information

PRIMARY INSURANCE COMPANY

Name of Insurance

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Primary card holder

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Relationship to patient

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Primary cardholder employer

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Work phone #

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Primary cardholder birthday

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SSN

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SECONDARY INSURANCE COMPANY

Name of Insurance

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Primary card holder

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Relationship to patient

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Primary cardholder employer

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Work phone #

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Primary cardholder birthday

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SSN

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Policies and Consents

**Medical Photography Consent: Medical photographs may be taken and stored in patients’ electronic medical chart. **HIPAA Consent Policy: With my consent, Ozark Dermatology Clinic (ODC) may use and disclose my protected health information to carry out treatment, payment and healthcare operations (TPO). I understand that I have the right to review ODC's Notice of Privacy Practices and have been given the opportunity to do so. With my consent, ODC may call my house or other designated locations and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, lab results and insurance information among others.

Signature of PATIENT (Parent or Guardian)

Clear

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Print PATIENT'S name

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Date

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My private information can be released to the following persons:

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Payment and Insurance Policy: To avoid a $35 fee, a 24 hour cancellation notice is required.
Payment is due upon completion of today's office visit. If you have insurance, we will be happy to process your claim, but we request that you pay your estimated portion at the time of service. This includes any co-pays, percentages and deductibles. We require that all insurance payments are hereby assigned to Ozark Dermatology Clinic for services rendered to the patient or dependent. Charges denied due to insurance policy limitations will be transferred to the patient or guarantor. Payment for any treatment deemed by insurance companies to be cosmetic or not medically necessary is the responsibility of the patient. FAILURE TO KEEP SURGERY APPOINTMENTS WILL RESULT IN TERMINATION OF CARE FROM OZARK DERMATOLOGY CLINIC.

Signature of PATIENT (Parent or Guardian)

Clear

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Print PATIENT'S name

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Date

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