Fine Skin

Pre-Registration

For your convenience, click the PDF icon to download a Registration form, you can print, fill and bring it with you.

You may also choose to fill this form electronically here and submit to us, to save time when you visit our office

Patient's Information

Last Name *

First Name *

Middle Name

Address

City

State

Zip

Marital Status

Single

Married

Divorced

Widow

Sex

Male

Female

Social Sec.

Birthday

Home Phone

Work Phone

Emergency

;

Cell Phone *

E-mail *

Referral Doctor

Primary Insurance Coverage

Company

Insured Name

Relationship

Date of Birth

Co-Payment Amount

Policy Number

Group Number

Employer

Secondary Insurance Coverage

Company

Insured Name

Relationship

Date of Birth

Co-Payment Amount

Policy Number

Group Number

Employer

Guarantor Information

Guarantor

Address

City

State

Zip

Telephone

Miscellaneous

Patient’s Authorization

I authorize FineSkin, Dr. Renuka H. Bhatt to apply for benefits on my behalf for services rendered by FineSkin. I request payment from my insurance company be made directly to FineSkin, Dr. Renuka Bhatt. I certify that the information I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information for this or any related claims. I permit a copy of this authorization to be used in place of the original. This authorization may be revoked by me at any time in writing. I understand that nothing herein relives me of the primary responsibility and obligation to pay for medical services provided, when a statement is rendered.