Skincare Intake, Demo & HIPAA

Advanced Specialty Care Skincare: Patient Intake

If the patient is a child, fill out the form as it pertains to the child.
Which office are you being seen in? *
Please select the office location from the drop-down
Patient Registration
Patient Name *

First Name M.I. Last Name
Gender *

Male Female
Date of Birth *

Month Day Year
Age *
Social Security #
Street *
City *
State *
Zip *

Phone Number (please provide at least one phone number) *

Phone Number

Cell Phone

Home Phone

Work Phone

Home Phone
Cell Phone
Work Phone
Email Address
Select ONE contact method for appointment reminders *
Opt out of promotional practice emails. (You may also opt out at any time by calling (203) 830-4700.)
Please Note: $50.00 No Show fee will be charged to your credit card if no show or you do not cancel within 24 hours
Primary Doctor
Primary Doctor Location (City/State)
Was this your referring physician?

Yes No
If no, who was your referring physician?
Responsible Parent/Guardian

First Name M.I. Last Name
Parent/Guardian Date of Birth

Month Day Year
Parent/Guardian Home Phone
Street
City
State
Zip

Advanced Specialty Care Skincare: Patient Intake