Patient’s Name ___________________________________________________________

                           First Name                Initial                Last Name

Date of Birth (DOB): ________ Sex ___ M ___ F Social Security # _________________

Address: ________________________________________________________________

City ______________________________ State _______________ Zip ______________

Home Phone: ______________Work Phone: ________________Email______________

Employer: ___________________________Occupation: _________________________

Marital Status: ____________Name of Spouse: _________________________________

Subscriber Name on Insurance: ______________________________DOB: ___________

Name of Parents (if a minor): _______________________________________________

Address if Different from Patient: ____________________________________________

Person Responsible for Payment: ____________________________________________

Employer: ____________________ Address: __________________________________

Person to Contact in Case of Emergency: ______________________________________

Telephone: _______________________________________________________________

…………………………………………………………………………………………….

Do you have Tuberculosis (TB)? _____ Yes _____ No

Is there a specific laboratory your insurance requires to be used? _____ Yes _____ No

If yes, which Laboratory? __________________________________________________

Does your insurance require a predetermination for foot care? _____ Yes _____ No

………………………………………………………………………………………………

INSURANCE INFORMATION

Insurance Company: ______________________________________________________

Address: _______________________ City: __________________ State: ___ Zip: _____

Subscriber Name: __________________________________________ DOB: _________

Contract # _____________________________________ Group # __________________

Service Code and/or Plan Code: _____________________________________________

Does this plan cover all family members? _____ Yes _____ No

LifeTime Dermatology 2221 Livernois, Suite 101 Troy, Mi 48083 I authorize the release of any medical information necessary to process my insurance claim and I authorize payment of medical benefits to be made to the provider listed above for the services rendered. ____________________         ______________________________________________ Date                                      Signature of Patient or Parent if patient is a minor