Home
Patient Forms

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 *

First and Last Name*:

Address*:

City*:

State*:

Zip Code*:

Home Telephone Number*:

Work Telephone Number:

Mobile Telephone Number:

Email address*:

Prior name:

Date of Birth*:

Marital Status:

Single

Married

Divorced

Widowed

Sex:

Male

Female

Employment Status:

Employed

Part-time Student

Full-time Student

Other

Race*:

American Indian or Native Alaskan

White

Asian

Native Hawaiian or other Pacific Islander

Black or African American

Other Race

Ethnicity*:

Hispanic or Latino

Non-Hispanic or non-Latino

unknown/not reported

Preferred Language:

How did you hear about us?

Dr.

Insurance Plan

Hospital

Family

Friend

Close to home/work

Yellow Pages

Internet search

Print advertisement

Yelp

Other:

Social Security Number:

Primary Care Physician:

Responsible Person (if applicable)

Name:

Date of Birth:

Relationship to Patient:

Address:

City:

State:

Zip Code:

Home Telephone Number

Occupation:

Employer:

Employer phone :

Employment Information

Patient Occupation:

Patient Employer:

Patient Employer Address:

City:

State:

Zip Code:

In Case of Emergency (not at home of patient)

Name:

Address:

City:

State:

Zip Code:

Home Telephone Number

Relationship to Patient:

Primary Insurance Information

Name of Insured:

Insurance Company :

Date of Birth :

Relationship to Patient:

Insured ID # :

Group # :

Secondary Insurance Information

Name of Insured:

Insurance Company :

Date of Birth :

Relationship to Patient:

Insured ID # :

Group # :

How were you referred to our office?

By a Doctor

By a Patient

By a Seminar

Website

Other

Are you interested in Cosmetic Dermatology information?

Botox

Dermal Fillers

Skin Care Programs

Chemical Peels

Brown Spot Removal

Spider Vein Treatment

Laser Hair Removal

Laser Skin Rejuvenation

Would you like us to schedule a cosmetic consultation? Yes No

Comments or questions:

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

Yes No

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

Name #1:

Relationship to Patient #1:

Telephone (day) #1:

Telephone (evening) #1:

Name #2:

Relationship to Patient #2:

Telephone (day) #2:

Telephone (evening) #2:

What is the name of your
primary care physician?

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*:

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.

PATIENT RESOURCES

SECTION OVERVIEW
Medical History Forms
Skincare Questionnaire
Concierge Services
Vivicare Health Library
FAQs

featured video

HOW CAN WE HELP?

Medical History Forms
Special Offers
Before & After Gallery
Additional Resources

testimonials

raymonds, Tucson

"Clinic was very flexible in scheduling a procedure on the same day as my examination. They were also extremely responsive in analyzing a tissue sample within minutes of my appointment which permitted a diagnosis and treatment plan to be developed immediately." Read More

jillianb, Tucson

"I always think the office people are so professional, super sweet and prompt! I think this is a great office. Everything is always clear and Naomi is not only so thorough and kind she always lets me know everything I dont even have to ask follow up questions!" Read More

heatherw, Tucson

"This is a very well-run practice. Form the time I walked in until the time I left, I felt as if everyone was working towards the same goal- excellent patient care. Dr. Glassier was warm & provided an excellent education at the same time. As a new patient, I can see why it took a while to get an appointment. It was well-worth the wait. Thank you!" Read More

madelaines, Tucson

"Staff and Dr. Glaesser are wonderful. Although appointment ran 1/2 hour late, I would still recommend highly. Judging by the waiting room, it must be one of the best practices around." Read More

barbarah, Oro Valley

"I am very happy to be seen by Dr. Fiona Behr each year for a thorough check-up and recommend her care to anyone."
Thank you. Read More

anonymous

"I'm so glad you asked. Both Shawn and Genevieve were kind, professional and efficient. I had a wonderful experience from the time I made the appointment to walking out the door. You have a lovely team."
Thank you. Read More

deborahr, Oracle

"Staff very friendly and knowledgeable. Sweet girls. Dr. Glasser gave me more information than I had received by other doctors. Glad I came to this office." Read More

williamd, Tucson

"Dr. Behr is always great, friendly, personable and yet very professional! I did not have to wait long and the staff at the front desk facilitated the processing that enabled this appointment to move smoothly." Read More

eugenes, Tucson

"Dr. Trout is one of the finest doctor's I've had treat me. Definitely a 10 out of 10. You won't find a better dermatologist in Tucson." Read More

joanf, Tucson

"I have been going to Ironwood for years. NEVER have had a bad experience. The front desk girls are kind, friendly, and most of all, efficient. I love Dr. Glaesser and her nurse. I have referred several people over the years. Carry on Ironwood, Carry on!" Read More

susang, Tucson

"Shawn was prompt and efficient as was Genevieve. Shawn examined me, burned off a particular issue on my chest that had been bothering me and completed a biopsy on one on my back. She was very thorough in her explanation. Thank you for your care of me!!" Read More

stephaniek, Tucson

"Professional front office staff, very short wait time, less than 5 minutes in the waiting room and less than that for Dr Dixon. I will always recommend Ironwood Dermatology to friends and family." Read More

*Result may vary from person to person

Previous Next