New Patient Registration Form - ADULTS (AGE 18 AND OVER)

New Patient Registration - ADULTS

Please fill out all fields below.
Patient Name *

First Name Middle Name Last Name
E-mail *
Sex *
Date of Birth *

Month Day Year
Please upload a photo of a government issued ID or valid form of identification

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Patients Social Security Number
Marital Status *
Patient Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Phone Number

Area Code Phone Number
Cell Phone Number *

Area Code Phone Number
Work Phone Number

Area Code Phone Number
May we leave detailed messages about your care on the following lines? *

Ok to leave message on home line Ok to leave message on cell Ok to leave message on work line I do not authorize McLean Dermatology to leave detailed messages about my care
Emergency Contact Information
Emergency Contact: *

First Name Last Name
Relationship to Patient *
Emergency Contact Number *

Area Code Phone Number
Billing Information

Please bring a photo ID and your insurance card to your appointment. Note: If you do not have insurance or are not using insurance for your visit, payment is due at the time of your visit.
It is your responsibility as the patient to understand your insurance plan limits and restrictions that affect coverage of services you receive. If you have a biopsy or any lab testing in our office, you and/or your insurance will be billed for the corresponding charges. The clinic for pathologies/lab is a third party and will bill you for remaining balances. If your insurance company requires you to use a specific laboratory/clinic for pathologies in order for fees to be covered, it is your responsibility to request this.

Our third-party facility for all our pathologies is Fairview Health Services located in Minneapolis, Minnesota. Their billing contact number is (866) 848-4863.

Our third-party facility for all our lab testing’s is LabCorp.
Do you have active health insurance? *

Yes No
Name of Primary Health Insurance Company
Primary Insurance ID Number
Name of Policy Holder

First Name Last Name
Policy Holder's Date of Birth

Month Day Year
Patient's Relationship to Primary Insurance Policy Holder
If you are the policy holder, please write SELF.
Please upload a photo of the FRONT of your primary insurance card.

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Please upload a photo of the BACK of your primary insurance card.

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Does your insurance require a specific Lab/Clinic for pathologies? If unsure, please contact your insurance. *

Yes No
If yes, please list where:
Name of Secondary Health Insurance Company (If applicable)
Secondary Insurance ID Number
Name of Secondary Policy Holder

First Name Last Name
Secondary Policy Holder's Date of Birth

Month Day Year
Relationship to Secondary Policy Holder
If you are the main policy holder, please write SELF.
Please upload a photo of the FRONT of your secondary insurance card.

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Please upload a photo of the BACK of your secondary insurance card.

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Does your insurance require referrals to specialists? *

Yes No
Name of Referring Physician (If Applicable)
Please note: If your insurance requires referrals, you must obtain the referral prior to your visit. Referrals must be processed through your insurance and have an authorization number to be valid. Referrals may be faxed to us prior to your visit at(703) 388-0873 or emailed to info@mcleandermatologycenter.com.
Referring Physician Phone Number (If Applicable)

Area Code Phone Number
Your Care Team
Name of Primary Care Physician
Primary Care Physician Phone Number

Area Code Phone Number
Preferred Pharmacy Name
Preferred Pharmacy Phone Number

Area Code Phone Number
Preferred Pharmacy Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please list the names and relationships of individuals who we may speak to about your medical records and billing matters related to your account. (Please note: if no one is listed here, we will not be able to discuss your account with anyone other than you.) *
Health History
Please list the names of any medications you currently take, including over-the-counter medications. If you are not taking medications, please write "No medications." *
If you have a medication list, please feel free to upload a copy of it here:

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Do you have drug allergies? Please list the names of medications you are allergic to here. If you do not have drug allergies that you are aware of, please write "No known allergies." *
Do you have any of the following health conditions? Select all that apply. *

Abdominal Pain Allergy to Topical Antibiotic Ointments Allergy to Adhesive Allergy to Cow Milk Protein Allergy to Latex Allergy to Lidocaine Anxiety Arthritis Artificial Heart Valve Artificial Joints within Past 2 Years Atrial Fibrillation (Irregular Heartbeat) Bloody Stool Bloody Urine Breastfeeding Cancer Changing Mole Chest Pain Coronary Artery Disease Cough Currently taking Blood Thinners Defibrillator Depression Diabetes Eczema End State Renal Disease Fever or Chills GI Upset with Antibiotics Hay Fever/Allergies Headaches Hearing Loss Hepatitis High Blood Pressure High Cholesterol HIV/AIDS Hyperthyroidism Joint Aches Immunosuppression Kidney Disease Mastectomy - Left Side Mastectomy - Right Side Double Mastectomy Muscle Stiffness Muscle Weakness Organ Transplant Pacemaker Currently Pregnant Planning a Pregnancy Problems with Bleeding Problems with Scarring (Hypertrophic Scars or Keloids) Psoriasis Rapid Heartbeat with Epinephrine Require Premedication Prior to Procedures Rash Seizures Shortness of Breath Sore Throat Thyroid Problems Tuberculosis Unintentional Weight Loss Wheezing Yeast Infection with Antibiotics Tanning Bed Use Liver Disease Former Smoker Current Smoker Alcohol Use Recreational Drug Use None of these
Please list all other pre-existing health conditions, if applicable.
Please list all previous surgeries
Have you had skin cancer? *

No I have not had skin cancer Yes, history of Basal Cell Carcinoma (BCC) Yes, history of Squamous Cell Carcinoma (SCC) Yes, history of Melanoma
Has anyone in your family had skin cancer? *

No family history of skin cancer Yes, family history of Basal Cell Carcinoma (BCC) Yes, family history of Squamous Cell Carcinoma (SCC) Yes, family history of Melanoma
Please specify which family members have had skin cancer. *
Cosmetic Concerns

(Optional)
I would like to know more information about the following skincare products?

Eye Creams Sunscreen Retinols Cleansers Scar Creams Moisturizers Anti-Aging Serums Anti-Aging Moisturizers
I have the following cosmetic concerns:

Aging Skin Downturned Mouth Fine Lines/Wrinkles Age Spots/Brown Spots/Sun spots Skin Discoloration Under eye circles Unwanted fat on the belly/love handles/back/arms Crows Feet Loose Skin/Sagging Skin Loss of Facial Volume Uneven Skin Texture Acne Scarring Facial Redness Urinary Incontinence
I would like more information about the following cosmetic procedures:

Botox, Dysport, or Xeomin Anti-Aging Lasers (Fine Lines/Wrinkles) Fillers to Soften Facial/Hand/Neck Lines Lasers to Reduce Facial Redness Sclerotherapy (Spider/Varicose Veins) Latisse (Eyelash/Eyebrow Growth) Skin Tightening CoolSculpting Treatment Options for Excessive Sweating Kybella (Injections for Permanent Reduction of Chin Fat)
How did you hear about McLean Dermatology and Skincare Center? *

Family/Friend (Please write name in "Other" box) Insurance Company Physician Social Media Publication (medical journal, magazine article, etc.)
Financial Agreement
Financial Agreement

At McLean Dermatology and Skincare Center, we are committed to providing the best dermatologic care.

Please note: This agreement must be signed in order to be seen by providers at McLean Dermatology and Skincare Center

OFFICE FEES AND PAYMENTS
- There are fees for all services performed by our providers and staff, including consultations and procedures.
- As the patient or guarantor, it is your responsible for all charges for your visits, including co-payments, deductibles, and coinsurance amounts that are due per your insurance plan.
- Cosmetic services cannot be processed through insurance, and fees for such services are due at the time of service. Allbsales are final.
- General dermatology services will be processed through the insurance on file or billed directly to the patient if we dobnot have insurance on file.
- If there is a balance due after insurance pays for your visit, the difference owed is patient responsibility.
- Charges for all visits and procedures that are not processed by insurance are due at the time of service.
- Medicare patients are responsible for any bala{signature}{signature}nces due for services that are not covered by Medicare.
- If you have an outstanding balance on your account, it must be paid in full before your next visit.
- We accept cash and all major credit cards. We do not accept checks.
- For any NSF check (checks returned for non-sufficient funds), a $50 NSF charge will be billed to your account.
- If proof of insurance is not provided at the time of service, you are responsible for the entire fee for the consultation and/or procedure at the time of service, and a $150 service fee for retroactively billing your insurance.
- In the case of an account overpayment, a credit will remain on your account unless you request a refund.
INSURANCE POLICIES
- Your insurance policy is a contract between you and your insurance company. It is essential that you understand which services and procedures are covered by your insurance plan and obtain any necessary authorizations or referrals prior to your appointment with us.
- We accept plans through the following payers as in-network providers: UnitedHealthcare, Cigna, Medicare, Virginia Health Network, Carefirst BlueCross BlueShield, First Health, and PPO plans by Anthem Blue Cross Blue Shield.
- We cannot guarantee that we accept your specific plan as an in-network provider; it is your responsibility to verify your insurance benefits and coverage prior to your visits.
- We will not submit claims to any other insurance company other than those listed above. If you have a secondary insurance in addition to one of the plans listed above, we will file a claim to your secondary insurance as an out-of-network provider. In such instances, we cannot guarantee complete coverage.
- If we do not accept your insurance, the charges for all services are due in full at the time of service. All sales are final.
- Please note: several United Student Resources plans do not cover hair loss visits; verify your coverage and benefits prior to your visit so you are aware of your plan benefits and limits.
- It is your responsibility as the patient to understand your insurance plan limits and restrictions that affect coverage of services you receive.
- If you have biopsy or any lab testing in our office, you and/or your insurance will be billed for the corresponding lab’s charges. The lab is a third party and will bill you for remaining balances.
- If your insurance company requires you to use a specific laboratory in order for laboratory fees to be covered, it is your responsibility to request this.
48-HOUR CANCELLATION POLICY
- You will be billed a $50 “No Show/Cancellation Fee” for each consultation cancelled or missed without 48-hour notice, or $150 for all missed Saturday appointments without 48-hour notice.
- You will be billed a $150 “No Show Fee/Cancellation” for all procedure appointments cancelled/missed without 48-hour (Excisions, lasers, Botox, fillers, etc.)
COLLECTION AGENCY
- In the event it is necessary to refer your account to a collection agency, you will be responsible for all fees of any collection agency, which may be based on a percentage at a maximum of 30% of the debt, and all charges accrued, including attorney fees, court costs, late fees, an 8% interest fee, and all McLean Dermatology and Skincare Center PLLC administrative fees.
By signing this agreement you acknowledge that you have received and read the Financial Agreement, and dully understand and accept the terms of the McLean Dermatology and Skincare Center Financial Agreement.
Signature of patient OR Guardian/Parent For Financial Agreement: *

Clear
Privacy Practices

*You authorize the release of any medical or other information necessary to process claims related to general dermatology (medical) services received by yourself or your dependent. You assign all medical payment on your behalf or that of your dependent for services provided to be issued to McLean Dermatology and Skincare Center, PLLC, 6849 Old Dominion Dr. Suite 450, McLean, VA 22101. *We are required by law to provide you with a copy of our Notice of Privacy Practices.
I have received and read the Notice of Privacy Practices, and dully understand and accept the terms of the McLean Dermatology and Skincare Center Notice of Privacy Practices. *
Patient Name *

First Name Last Name
Signature *

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Date Signed *

Month Day Year
Date
Should be Empty:

New Patient Registration - ADULTS

Emergency Contact Information

Billing Information

Your Care Team

Health History

Cosmetic Concerns

Financial Agreement

Privacy Practices