• Image field 3

  • PATIENT INFORMATION

  • This section must be completed for all patients

  • Today's Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Marital status
  •  -
  • Format: (000) 000-0000.
  •  -

  • PARENT SPOUSE OR RESPONSIBLE PARTY (If different from patient)

  •  -
  •  -
  •  -
  • Would you like to access your charts via Intelichart, our secure Patient Portal?

  • INSURANCE COVERAGE - PRIMARY

  • Policy holder insured (DOB)
     - -
    2 digit month, 2 digit day, 4 digit year
  • If parent or Guardian, please specify relationship to the patient

  • INSURANCE COVERAGE - SECONDARY

  • If parent or Guardian, please specify relationship to the patient

  • Please present your insurance card(s) and a photo id to the front desk Thank you

  • Image field 56

  • BIOPSY CONSENT

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • As a part of your visit with Kimberly U. Hurvitz, M.D. you may require a skin biopsy(s) to confirm or diagnose your skin condition. Al! procedures carry some risks; these include possible scarring, bruising, allergic reaction, infection and nerve damage. Please inform our office if you are allergic to any medications and if you have recently taken Aspirin, Advil, Aleve, Motrin, Ibuprofen, and any blood thinners (Coumadin).

    I authorize the performance of a biopsy(s) by Kimberly U. Hurvitz, M.D. I consent to the administration of local anesthetic, as needed, and have informed the doctor that I am allergic or have severe reaction to the following medications.

  •  -

  • I HAVE READ THE ABOVE INFORMATION AND AGREE TO HAVE THIS PROCEDURE PERFORMED IF DEEMED NECESSARY BY KIMBERLY U. HURVITZ, M.D.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
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  • FINANCIAL POLICY 

    I hereby authorize treatment by Kimberly Uhles Hurvitz, M.D. and understand that I am financially responsible for all fees and charges for such treatment whether or not they are covered by my insurance policy. I understand Dr. Hurvitz is contracted with some, but not all, insurance plans and it is my responsibility to be aware of the terms and limitations of my insurance coverage. If my insurance policy is through and HMO, I understand it is my responsibility to ensure that authorization has been obtained from my primary care physician prior to receiving services from Dr. Hurvitz. If such authorization has not been given, I understand that I will be financially responsible for all fees and charges.

    I understand that during the course of my office visit with Dr. Hurvitz, it may be necessary for him/her to perform additional diagnostic or therapeutic services at his/her discretion. I understand that charges for these services will be in addition to the regular office charges.

    I authorize Dr. Hurvitz to furnish any medical information necessary to process my claim to my insurance carrier and hereby irrevocably assign to the doctors payment for medical services and unpaid balances. I authorize copies of this authorization to be used in place of the original. If my account is referred to an attorney or collection agency, I agree to pay reasonable fees and collection expenses. I understand that all balances overdue by 60 days or more will be subject to a finance charge of 1.5% per month on the unpaid balance, whether or not an insurance claim is pending.

    I have received a copy of the Privacy Notice from Advanced Dermatology & Aesthetics Center.

    This authorization will remain in effect until revoked by me in writing.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • IF PATIENT IS A MINOR, PLEASE COMPLETE THE FOLLOWING:

  • and agree that I am financially responsible for all fees and charges for such treatment.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Thank You 

  • Image field 78

  • PATIENT CARE FINANCIAL AGREEMENT
    Kimberly Uhles Hurvitz, MD

    The purpose of this agreement is to provide a clear understanding of our appointment cancellation policy.  We require at least a 24 hours notification of cancellation prior to your scheduled appointment. Failure to do so may result in a fee.

    Late Cancellation/No Show Appointment Fee for Kimberly Hurvitz, M.D. is $150 per appointment and $300 for surgical procedures

    We appreciate the time that we are able to spend with you.  We diligently strive to be prepared and on time for your appointments so that you receive the maximal benefit from your time at Advanced Dermatology & Aesthetics Center.  If you are unable to keep your appointment, please notify us as soon as possible.

  • I hereby authorize this office to charge my account $150-$300 should I fail to cancel an appointment at least 24 hours in advance or miss a scheduled appointment.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • IF PATIENT IS A MINOR, PLEASE COMPLETE THE FOLLOWING:

  • I authorize treatment of      and agree that I am financially responsible for all fees and charges due to failure of cancellation.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • This agreement has no expiration date 

  • MEDICAL HISTORY FORM

  • Today's Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • PATIENT INFORMATION

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Primary Language
  • Race
  • Ethnicity

  • REASON FOR TODAY'S VISIT 

  • PAST MEDICAL HISTORY

  • Melanoma History
  • Other skin cancer history
  • Rows
  • Rows

  • FAMILY HISTORY OF SKIN CANCER

  • Do you have a family history of melanoma?
  • Do you have a family history of other skin cancer(s)?

  • SOCIAL HISTORY

  • Marital status
  • Do you use tobacco?
  • If yes
  • Alcohol consumption
  • If yes
  • If daily how many per day
  • Do you use sunscreen
  • Tanning bed use

  • FOR WOMEN ONLY 

  • Are you pregnant ?
  • Are you breastfeeding?
  • Are you on birth control ?
  • Do you have irregular menstrual cycles
  • Current Medication
    Rows

  • MEDICATION ALLERGIES 

  • Do you have any medication allergies ?
  • If yes list all allergies and reactions
    Rows

  • ADDITIONAL SYMTOMS 

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  • AESTHETIC INTEREST QUESTIONNAIRE 

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Would you like to access your charts via our secure patient portal, called Intelichart?

  • Do you have any concerns about the following areas? Please check all that apply

  • Rows
  • Rows
  • Other than the services we have already provided for you, what else would you like to learn about?
  • Should be Empty: