Online Patient Registration Form
First Name
Telephone Number
Last Name
Work Phone
Current Address
Primary Insurance
City
Insurance ID #
State
Secondary Insurance
Zip
Sec. Insurance ID#
Employer
Date of Birth
Sex
First Visit
Insurance Policy Holder
Email address:
Relationship to Patient
ParentChildSpouse
Does your insurance require a referral?
Physician who referred you to our office
Medical History
Are you currently under medical treatment?
YesNo
Are you presently taking any medications?
Have you had an allergic reaction to any medications? (Please list)
Have you ever been treated for skin conditions in the past?
Are you currently applying any creams, ointments or solutions to your skin?
What would you like the Doctor to do for you?
I understand that payment is due at time of service and that I am responsible for payment of procedures not covered by my insurance policy(ies).
(Medicare patients only) I request that payment of authorized Medicare benefits be made on my behalf to Sheard & Drugge, P.C. for any services furnished to me. I authorize all medical information about me to be released to the Health Care Administration and its agents.