Patient Forms for Ironwood Dermatology

Start the Paperwork Now to Save Time

Step 1 of 2: Patient Registration

Instructions: this form can be completed on your computer. At the end of the form, you can click "Submit" to send it to our office. Please click on our General Office Policies section for important new patient information.

Patient Information

Required fields in Bold text and denoted by *

Single

Married

Divorced

Widowed

Male

Female

Employed

Part-time Student

Full-time Student

Other

American Indian or Native Alaskan

White

Asian

Native Hawaiian or other Pacific Islander

Black or African American

Other Race

Hispanic or Latino

Non-Hispanic or non-Latino

unknown/not reported

Responsible Person (if applicable)

Employment Information

In Case of Emergency (not at home of patient)

Primary Insurance Information

Secondary Insurance Information

How were you referred to our office?


Are you interested in Cosmetic Dermatology information?


Would you like us to schedule a cosmetic consultation?

Comments or questions:

Do you give our office permission to discuss medical/financial information with another party?



If yes, please provide their names and phone numbers below:

Consent to Treatment

I voluntarily consent to receive medical, health care and/or cosmetic services that may include diagnostic procedures, examinations and treatment.

Financial Responsibility and Assignment of Benefits

I have been provided with a copy of Ironwood Dermatology's financial policies. I agree to pay all charges for medical and health care services not covered by my insurance company including interest and collection costs associated with collecting delinquent balances.

Please enter your name in this box agreeing you understand the above terms*:

security code

PLEASE NOTE

When you click on "Submit," your form will be forwarded to our practice. If your computer's security is set high, or you have certain pop-up blockers, or anti-spyware, you might get this same screen again instead of a screen acknowledging that the form has been submitted. Your form has been sent, however. If you have any question about your form getting to us, please call us at (520) 618-1630.

* Your Email address will be used to send updates and promotions for Medical and Aesthetic skincare services. If at any time you would like to stop receiving emails from us you can unsubscribe and we will not send you any further emails. Please know that we will not provide any of your information to a 3rd party vendor not working with us. Your information will always remain confidential.