Language
  • English (US)
  • Patient Information

    Please complete this form before your visit. This form is for all patients (new and existing, telehealth/virtual and in-person visits). If you are under 18, please have your parent/guardian complete and sign this form.
  • **Please note: To begin your telehealth visit, please follow this link: https://doxy.me/drdavidkhalil. Dr. Khalil will log into the video call at the approximate scheduled time of your visit. Due to in-office procedures, there may be a wait-time for your virtual visit. We greatly appreciate your flexibility and patience.

  • **Please note: Dr. Khalil will telephone you directly at the approximate time of your visit. Due to in-office procedures, there may be a wait-time for your virtual visit. We greatly appreciate your flexibility and patience.

  •  -
  • Browse Files
    Cancel of
  • Emergency Contact (optional)

  •  -

  • Medical Information

  • Several clear photos of the skin condition are recommended for virtual visits. If you are not able to send photos using the below, please email the images to info@dkdermatology.com or upload the images to your Patient Portal account at www.dkdermatology.com/portal. 

  • Browse Files
    Cancel of
  • Browse Files
    Cancel of
  • Browse Files
    Cancel of
  • Browse Files
    Cancel of
  • Browse Files
    Cancel of
  • Browse Files
    Cancel of


  • We recommend full body skin exams to check for skin cancer at least once per year for all adults. Please schedule with the front desk if you are interested.

  • Cosmetic Services

  • BOTOX® - BOTOX® helps to relax the muscles in the face and injections typically take only 15-30 minutes in-office, requiring no downtime--it is also a highly effective treatment for excessive sweating and underarm odor, no antiperspirant needed! Please note that if you are trying to conceive, pregnant, and or breastfeeding, you cannot receive BOTOX® injections.

    Skin dermal fillers - Different from BOTOX®, fillers are made of a natural substance called hyraulonic acid and help to add volume to the treated areas. Injections typically take only 15-30 minutes in-office and require no downtime. We only use JUVÉDERM® and BELOTERO BALANCE®-brand fillers to ensure the most natural-looking results! Please note that if you are trying to conceive, pregnant, and or breastfeeding, you cannot receive dermal filler injections.

    Chemical peel - Medical-grade chemical is applied in-office to the face or other areas for treatment to rejuvenate the skin and help decrease the appearance of blemishes--we typically recommend 3 sessions at 2 week intervals for the best results.

    Cosmetic mole removal - The skin around the unwanted mole is numbed and then excised with a medical-grade razor. Dr. Khalil has successfully performed over 3,000 mole removals to date!

    Milia (white spot) removal - Tiny cysts in the skin that can only be removed by a physician, the areas for treatment are numbed then incised and drained with our thinnest medical-grade needle.

  • Medical Insurance

  • Accepted Medical Insurances: 

    -Aetna (including Meritain Health, Nippon Life Insurance, Trustmark, and other Signature Administrators)

    -Blue Cross Blue Shield (except member ID prefix JLJ and/or Gatekeeper plans). Please note that if your insurance card says "EPO" a referral may be required.

    -Centivo

    -Cigna (including HealthPartners)

    -EmblemHealth HIP (except Enhanced Care, Essential policies, and GHI). A referral is required for most HIP plans.

    -Medicare

    -Oscar

    -UnitedHealthcare Liberty, Freedom, Choice Plus, and Choice policies only

     

    We do not accept: GHI, Fidelis, Medicaid, Healthfirst, HealthShare plans (such as MultiPlan, PHCS, OneShare, Trinity HealthShare, etc.), or Worker's Compensation policies. We are not in-network with any Medicaid, including as a Medicare Supplement. If you have Medicaid as a Secondary Insurance/Medicaid Supplement, you must pay these charges out-of-pocket.

     

    Please Note: If you have two insurances and or a Medicare Supplement, please list both in the correct order (or the insurance companies will deny your visit claim). If we are not in-network with your Secondary Insurance/Medicare Supplement and you do not have out-of-network benefits, you may receive a bill for which you are responsible to pay.

     

    Referrals (important): All insurance cards that say HMO, PCP Selection Required, the name of your PCP (Primary Care Physician), Gated, Gatekeeper, Aetna Columbia Univerisity Student Health Plans, Centivo, and EmblemHealth HIP require referrals from your assigned PCP (Primary Care Physician). Also, many BCBS EPO plans require referrals. For Columbia students, this referral must be provided by a PCP at the Columbia University Student Health Center and submitted to Aetna by Columbia staff for processing. Referrals for Columbia students expire at the end of the applicable semester. For Centivo policies, this referral must be submitted electronically from the Centivo app by your assigned PCP. For EmblemHealth HIP policies, your assigned PCP must provide you with a valid referral on the EmblemHealth mandated referral sheet. Please note that generic referral slips are not considered valid by insurance companies and will be denied.



  •  -  -
    Pick a Date
  • Clear photos of both sides of the insurance card are required. If you are not able to submit photos using the above, please email them to info@dkdermatology.com or upload them to your Patient Portal at www.dkdermatology.com/portal. 

  • Browse Files
    Cancel of
  • Browse Files
    Cancel of
  • Clear
  • Browse Files
    Cancel of
  • Browse Files
    Cancel of
  •  -  -
    Pick a Date
  • Medical Insurance Terms & Information

  • Copay - The fixed amount you pay for a health care service at the time of your visit.

    Deductible - The amount you must pay out-of-pocket for healthcare before your insurance pays. If you have an unmet deductible, you will receive a bill after your visit even if we are considered a "covered, in-network physician". An office visit is usually several hundred dollars, and the exact price is determined by the insurance company and not by the provider. 

    Coinsurance - The percentage of healthcare costs you must pay once your insurer covers its share.

    Specialist Visit - All dermatology visits are considered "Specialist Visits" by insurance companies. Specialist fees apply, including but not limited to specialty copays, coinsurances, and deductibles. Please note that dermatology visits are not considered "preventative" by insurance companies, including for annual skin exams/skin cancer screenings.

    **Please contact your insurance company if you have any questions about your individual policy's applicable coverage and costs before your visit.**

  • **Please contact your insurance company if you have any questions about your individual policy's applicable coverage and costs before your visit.**

  • **Please contact your insurance company if you have any questions about your individual policy's applicable coverage and costs before your visit.**

  • **Please contact your insurance company if you have any questions about your individual policy's applicable coverage and costs before your visit.**

  • **Please contact your insurance company if you have any questions about your individual policy's applicable coverage and costs before your visit.**

  • Pharmacy Information

  • Consent

  • I have completed this form accurately and completely. I am responsible for any information that is omitted and hold the provider harmless for medical decisions made without this information.

    I understand that it is my responsibility, and not the responsibility of the office, to know the benefits and limitations of my insurance. I understand that I am responsible for charges not paid by my insurance company. These include but are not limited to: copays, deductibles, coinsurances, procedures, lab tests, and referrals. I understand that it is my responsibility to know whether or not my insurance covers non-emergency care in New York state. If a referral is required, it is my responsibility to know this and to have a referral on the correct insurance form prior to my visit or I will be responsible for the entire visit cost. I understand that it is my responsibility to know if the physician and lab is a contracted in-network physician/facility recognized by my insurance plan, or I may be responsible for out-of-network charges. I understand that the provider does not accept and is not in-network with any Worker's Compensation-related insurance packages/polices or any Medicaid, including as a Secondary Insurance and or Medicare Supplement. I understand that if the provider is not in-network with my Secondary Insurance/Medicare Supplement, I may receive a bill for which I am liable to pay. I understand that the provider does not accept any HealthShare plans, including but not limited to MultiPlan, PHCS, OneShare, Trinity HealthShare, and more.

    I agree that DK Dermatology PLLC may use my health information for diagnosis, treatment, payment, insurance billing, credit card payments and chargebacks, and other such healthcare operations. I consent to access and share my medical information with my insurance company, relevant medical providers (such as my Primary Care Physician/PCP), pharmacies, and hospitals via telephone, fax, email, and or voicemail. 

    I acknowledge receipt of the Notice of Privacy Practices. The Notice of Privacy Practices may change at any time, and I can obtain a copy at the front desk or via email. I agree that by including my phone number and or email address, I am consenting to be contacted via phone, text, voicemail, and email with my medical information. 

    I understand that telehealth/virtual visits are processed by insurance companies like in-person visits, and I may be responsible for any applicable copays, coinsurances, and deductibles. I understand that many but not all skin conditions can be diagnosed and treated through a telehealth/virtual visit, however, a telehealth/virtual visit is not as accurate as an in-person visit. Telehealth/virtual visits are not refundable. 

    By signing this form, I confirm that I understand the following definitions:

    Copay - The fixed amount you pay for a health care service at the time of your visit.

    Deductible - The amount you must pay out-of-pocket for healthcare before your insurance pays. If you have an unmet deductible, you will receive a bill after your visit even if we are considered a "covered, in-network physician". An office visit is usually several hundred dollars, and the exact price is determined by the insurance company and not by the provider or their office.

    Coinsurance - The percentage of health care costs you pay once your insurer covers its share.

    Specialist Visit - All dermatology visits are considered "Specialist Visits" by insurance companies. Specialist fees apply, including but not limited to specialty copays, coinsurances, and deductibles. Please note that dermatology visits are not considered "preventative" by insurance companies, including for annual skin exams/skin cancer screenings.

    I understand that if a biopsy/excision site requires sutures/stitches, I must return in 7 days for suture removal, wound check, and a discussion of the pathology results. I acknowledge that this follow-up visit is subject to copays, coinsurances, and deductibles and that these charges are not included in the initial encounter/consultation office visit.

    I understand that it is my (the patient's) responsibility to schedule follow-up visits, especially if my condition is not improving, not responding to treatment, worsening, bleeding, hurting, enlarging, and or changing. I will not hold the office liable if my condition worsens due to my lack of follow-up. I also acknowledge that it is my responsibility (the patient's) to inform my provider if I have had a blood draw, bacterial culture, viral culture, imaging procedure, skin biopsy, or other such procedure done and have not heard back from my provider in 10 business days or less with the results, as sometimes outside facilities do not always send results to the ordering provider in a timely manner.

    To protect against the transmission of blood-borne diseases if an accidental blood or bodily fluid exposure occurs, I understand and agree that it may be necessary to test my blood for certain diseases (such as Hepatitis and Human Immunodeficiency Virus/HIV).

    It is recommend for all adults to have (at least) yearly skin exams to check for skin cancer by a dermatologist and monthly self-skin checks. I understand it is my responsibility to schedule skin exams if I am interested. I also understand that most insurance companies do not consider annual skin exams by a dermatologist to be "preventative" and may not offer "preventative" coverage for said exams. 

    If I am paying by credit card, I agree that my credit card will be kept on-file and used for healthcare payments (such as copays, coinsurances, and deductibles) by the Elavon secure credit card processing system. I agree that if I cancel my appointment without providing 24 hours of advance notice that I will be responsible for a $50 fee. 

    I understand that if I have an outstanding balance with the practice (whether due to Self-Pay charges, insurance copay charges, insurance coinsurance charges, insurance deductible charges, or any other such charge) it is my responsibility to pay off this balance in a timely manner. If my bill is not paid in full by me and or my insurance company within 90 calendar days of my visit, I understand that my account may be adjudicated by a collections agency, for which I am therefore responsible for any collections fees, legal fees, or other such fees.

    By signing below, I certify that I understand and agree to this consent form.

  • Coronavirus (COVID-19) Consent

  • The office takes several precautions to prevent the transmission of COVID-19/coronavirus, including cleaning the office, wearing masks, and screening for symptoms of coronavirus. However, it is not possible to guarantee a 0% risk of exposure. By coming into the office, I understand that there may be a risk of exposure to coronavirus, and I do not hold the office responsible for this. 

    Signs, Symptoms, and Risk Factors of COVID-19/Coronavirus
    fever, chills, cough, fatigue, joint/muscle pain, headache, sore throat, congestion or runny nose, nausea, vomiting, diarrhea, loss of taste or smell (one of the earliest symptoms), shortness of breath, difficulty breathing, requiring more energy than usual to breathe, being in close proximity to a person with the above symptoms

    By coming to the office, I agree that I have not had any sign, symptom, or risk factor (see above) for COVID-19/coronavirus for at least 14 days before my visit.

    I agree to wear a mask on the day of my visit. I agree to keep my mask on inside the office for the entire duration of my visit unless asked to remove/lower my mask by the physician or other staff.

    I agree to not bring any guests or family members with me to my visit. I understand that I can instead include them by phone or video if applicable.

    By signing below, I certify that I understand and agree to this consent form. 

  • Clear
  •  -  -
    Pick a Date
  • ***Note: After clicking "Submit", please do not close your web browser until after the page has refreshed and you are redirected to the "Thank You" page.

  • Should be Empty:
Jotform Logo
Now create your own Jotform - It's free! Create your own Jotform