Get Serious About Your Skin ®

Today’s Date 5/14/2020

FINANCIAL
POLICY:
PATIENT I N FO R M AT I ON:
First Name Rick Last Name
Pink
Middle C
1669 Ripley Run Wellington FL 33414
•Address
Payment is due at the time of service, including co-payments
Apt. andCity
deductibles. State Zip
rickpink2012@yahoo.com
•E-Mail
All charges
Address will become the patient’s financial responsibility if your insurance carrier has not paid within 60 days.
•Home
All Phone ( 408
cosmetic 242-5157
procedures
) are paid at the time ofPhone
Work service.
( We do not bill these procedures to insurance
) ( 408 ) 242-5157
companies.
Cell Phone
11/12/1951
•Date
I understand
of Birth are done68that I many receive
that if blood work or biopsiesAge Social separate0843
SecurityaNumber Sex:
inovice from the laboratory or
Last four digits of your SSN only!
✔
oM oF
the pathology doctor
Marital Status: o S ✔ who
oM oW oD review and interprets my biopsy specimens
Iete
Spouse / Partner Name Targas at a later date. Phone ( 408 ) 329-2763
I will be responsible for paying all suchUber
invoices directly to the laboratory or physician. Driver
Employer (company name if self employed) Occupation
•Primary
I havePhysician
read and fullyJose
Joseph understand ClearlyDerm LLC’s financial policy. Office Phone ( 561 ) 784-4930
Preferred Walgreens On Forest Hill inWellington
Pharmacy Pharmacy Phone ( 561 ) 791-9218
**THIS SHOULD BE SIGNED BY THE PERSON RESPONSIBLE FOR PAYMENT.**
Iete Targas
Emergency Contact Wife
Relationship Phone ( 408 ) 329-2763
Signature: ______________________________________________
INSURANCE
Printed Name:INFORMATION: (IN ORDER TO BILL YOUR
___________________________ INSURANCE
Date: COMPANY, THIS SECTION MUST BE COMPLETED IN FULL)
___________
Care Plus
PRIMARY Insurance Policy Policy or ID # Group # 436765301 MDR00*P1
Relationship: ____________________________________________
Insurance Customer Service Phone Number ( 800 ) 794-5907
AUTHORIZATION
Policy TO(ifDISCUSS/RELEASE
Holder’s Information different than patient) MEDICAL INFORMATION & CONSENT FOR TREATMENT
(Optional) I authorize __________________________________,
First Name Last Name Middle who is my ______________________________
S.S. # Sex:
Last four digits of your SSN only!
oM oF

toDate
haveof access
Birth Work
to/discuss my medical Phone (
records. ) Employer
SECONDARY Insurance Policy Policy or ID # Group #
I o AUTHORIZE, o DO NOT AUTHORIZE, Clearlyderm employees to release my medical information through
Insurance Customer
telephone Serviceto
communication Phone Number
myself or the( identified
) people listed on my HIPAA form .
Policy Holder’s Information (if different than patient)
I o AUTHORIZE, o DO NOT AUTHORIZE, Clearyderm to leave medical information on my voice message on this
First Name Last
designated Name Middle S.S. # Sex:
telephone number: _______________________________________________ Last four digits of your SSN only! oM oF
Date of Birth Work Phone ( ) Employer
I o AUTHORIZE, o DO NOT AUTHORIZE, Clearyderm to send medical information to my phone via text message
on this designated telephone number: __________________________________________________
HOW DID YOU HEAR ABOUT US:
I ooAdvertisement
AUTHORIZE, ooMyDO NOT AUTHORIZE,
Doctor Clearyderm
o Family Member o Friend toosend
Saw medical
Your Signinformation
✔ toDirectory
o Insurance my emailoatInternet
the designated
o Other
email address: _________________________________________________________________
I AM INTERESTED IN ADDITIONAL INFORMATION ON:
You give ClearlyDerm
o Botox®: LLConand
Eases wrinkles theit’s healthcare
forehead; providers,
smooths authorization
lines around to perform
the eyes and mouth medical treatment, therapy and
medication that may
o Facial Fillers: be indicated.
Corrects volume loss Including but not limited to: biopsies, cryotherapy, ED&C, Laser Treatments Etc.
and wrinkles
o DermaSweep™ Microdermabrasion: Next generation microdermabrasion with customized skin infusions to treat sun damage, hyperpigmentation
X
_________________________________ and premature aging
X ______________________________________ X ____________
Facials
o Print & Extractions: Deep
Patient Name cleansing facial utilizing ultrasonic waves to gently treat various skin conditions
Signature and penetrate healing antioxidants deep
Date
into the skin
o Chemical Peels:
A PARENT ORtones
Refines, and clarifiesMUST
GUARDIAN skin ACCOMPANY A MINOR TO THE INITIAL VISIT
o Laser Hair Removal: Permanent hair reduction
MINOR CONSENT: THIS SHOULD
o Laser Treatments: For vascular (red) or pigmented (brown) spots BE SIGNED IF THE MINOR WILL
o ClearlyDerm™ Acne NOT BE Medical
Program: WITH A PARENT,
grade EXCEPT
skincare products; FOR
take THE
home INITIAL
regimens VISIT.
prescribed just for you to assist you in achieving and
maintaining healthy skin
I o Sclerotherapy
give the doctors and staff at ClearlyDerm permission to treat __________________________ in my absence.

XRECORD
_____________________________ X _________________________________ X ___________
RELEASE & ASSIGNMENT OF BENEFITS:
Print Patient Name Signature Date
I hereby authorize ClearlyDerm LLC to release pertinent information regarding my care to other physicians involved in my case and / or insurance
companies holding policies on me. I authorize my insurance company to directly remit payment to ClearlyDerm LLC for medical or surgical services
provided and billed.
X Rick Pink X X
Print Patient Name Signature Date

Get Serious About Your Skin ®

 Get Serious About Your Skin ®

FINANCIAL
FINANCIAL POLICY:
POLICY:
•• Payment
Paymentis isdue
dueat at
thethe
timetime
of service, including
of service, co-payments
including and deductibles.
co-payments and deductibles.
• All charges will become the patient’s financial responsibility if your insurance carrier has not paid within 60 days.
• All charges will become the patient’s financial responsibility if your insurance carrier has not paid within 60 days.
• All cosmetic procedures are paid at the time of service. We do not bill these procedures to insurance companies.
• All cosmetic procedures are paid at the time of service. We do not bill these procedures to insurance companies.
• I understand that if blood work or biopsies are done that I many receive a separate inovice from the laboratory or
• I understand
the that ifwho
pathology doctor blood work
review orinterprets
and biopsies my
arebiopsy
done that I may receive
specimens at a lateradate.
separate invoice from the
laboratory or the pathology doctor who review and interprets my biopsy specimens
I will be responsible for paying all such invoices directly to the laboratory or physician. at a later date.
I will be responsible for paying all such invoices directly to that laboratory or physician.
• I have read and fully understand ClearlyDerm LLC’s financial policy.
• I have read and fully understand ClearlyDerm LLC’s financial policy.
**THIS SHOULD BE SIGNED BY THE PERSON RESPONSIBLE FOR PAYMENT.**
***THIS SHOULD BE SIGNED BY THE PERSON RESPONSIBLE FOR PAYMENT***
Signature: ______________________________________________
Printed Name: ___________________________ Date: ___________
Signature
Rick Pink
Printed Name Date
Relationship: ____________________________________________
Relationship
AUTHORIZATION TO DISCUSS/RELEASE MEDICAL INFORMATION & CONSENT FOR TREATMENT
(Optional) I authorize __________________________________, who is my ______________________________
AUTHORIZATION TO DISCUSS/RELEASE MEDICAL INFORMATION & CONSENT FOR TREATMENT
to have access to/discuss my medical records.
Dr Joseph Jose
(optional) I authorize , who is my Primary Care Dr to have access to / discuss my
I o AUTHORIZE, o DO NOT AUTHORIZE, (Name) Clearlyderm employees to release my medical information through
(Relationship)
medical records.
telephone communication to myself or the identified people listed on my HIPAA form .

IIo AUTHORIZE,o
✔ AUTHORIZE,
o DO NOT
o DO NOTAUTHORIZE,
AUTHORIZE,Clearyderm
Clearlyderm employees
to leave medicaltoinformation
release myonmedical information
my voice message onthrough
this telephone
communication to myself or the identified people listed on my HIPPA form.
designated telephone number: _______________________________________________

IIo
o AUTHORIZE,o
✔ AUTHORIZE, DO NOT
o DO NOTAUTHORIZE,
AUTHORIZE,Clearyderm
Clearyderm
to to leave
send medical
medical information
information to myon my voice
phone message
via text messageon this designated
on this designated
telephone number (
telephone )number: __________________________________________________

IIo
o AUTHORIZE,o
✔ AUTHORIZE, o DO
DO NOT
NOTAUTHORIZE,
AUTHORIZE,Clearyderm to to
Clearyderm send medical
send information
medical to mytoemail
information at the designated
my phone via text message on this
email address: _________________________________________________________________
designated telephone number ( )

You
Io✔ give ClearlyDerm
AUTHORIZE, LLCNOT
o DO and it’s healthcare providers,
AUTHORIZE, Clearyderm authorization to perform
to send medical medical treatment,
information therapy
to my email and
at the designated email
medication that may be indicated. Including but not limited to: biopsies, cryotherapy, ED&C, Laser Treatments Etc.
address
X _________________________________ X ______________________________________ X ____________
You give
Print ClearlyDerm
Patient Name LLC and it’s healthcare providers, authorization to perform medical treatment,
Signature Date therapy, and medication
that may be indicated.
A PARENT OR GUARDIAN MUST ACCOMPANY A MINOR TO THE INITIAL VISIT
X X X Rick Pink
MINOR CONSENT: THIS SHOULD BE SIGNED IF THE MINOR WILL
Signature
NOT BE WITH A PARENT, EXCEPTPrinted
FOR THE Name
INITIAL VISIT. Date

A PARENT
I give the doctors and staff atOR GUARDIAN
ClearlyDerm MUST
permission ACCOMPANY
to treat A MINOR TO THE
__________________________ in my INITIAL
absence. VISIT
MINOR CONSENT: THIS SHOULD BE SIGNED IF THE MINOR WILL
NOT BE WITH A PARENT, EXCEPT FOR THE INITIAL VISIT
X _____________________________ X _________________________________ X ___________
Printthe
I give Patient Name
doctors and staff at ClearlyDerm Signature
permission to treat Date in my absence.
(Name)

X X X
Signature Printed Name Date

Get Serious About Your Skin ®

 Get Serious About Your Skin ®

FINANCIAL POLICY:
PA ST MEDI C AL HI S TORY: (PLEASE CHECK ALL THAT APPLY)
• Payment is due at the time of service, including co-payments and deductibles.
•Patient’s Name Date
Rick Pink 05/14/2020
All charges will become the patient’s financial responsibility if your insurance carrier has not paid within 60 days.
•❒❒ Anxiety ❒ Diabetes
All cosmetic procedures are paid at the time❒of ❒❒ Leukemia
service. We do not bill these procedures to insurance companies.
❒❒ Arthritis ❒❒ Renal Disease ❒❒ Lung Cancer
• I understand that if blood work or biopsies are done that I many receive a separate inovice from the laboratory or
❒❒ Asthma ❒❒ Hepatitis Type: r A r B r C ❒❒ Lymphoma
the pathology doctor who review and interprets my biopsy specimens at a later date.
❒❒ Atrial fibrillation ❒❒ Hypertension ❒❒ Pacemaker
✔
I will be responsible for paying all such invoices directly to the laboratory or physician.
❒❒ Bone Marrow Transplant ❒❒ HIV/AIDS ❒❒ Prostate Cancer
•❒I❒ have
Breastread
Cancerand fully understand ClearlyDerm LLC’s financial policy.
❒❒ Hypercholesterolemia ❒❒ Radiation Treatment
❒❒ Colon Cancer ❒❒ Hyperthyroidism ❒❒ Seizures
❒❒ COPD **THIS SHOULD BE SIGNED BY❒THE PERSON RESPONSIBLE FOR PAYMENT.**
❒ Hypothyroidism ❒❒ Stroke
❒❒ Coronary Artery Disease ❒❒ Inflammatory Bowel Disease
Signature:
❒❒ Depression
______________________________________________
❒❒ Glaucoma
Printed
❒❒ OtherName: ___________________________ Date: ___________
_________________________________________________________________________________
❒❒ None
Relationship: ____________________________________________

AUTHORIZATION TO DISCUSS/RELEASE MEDICAL INFORMATION & CONSENT FOR TREATMENT

PA ST SUIRauthorize
(Optional) G I C AL HI S T ORY: (PLEASE CHECK ALL THAT APPLY) who is my ______________________________
__________________________________,
to
❒❒have access
Appendix to/discuss my medical records. ❒❒ Coronary Artery Bypass
Removed ❒❒ Ovaries Removed Due To:
❒❒ Bladder Removed ❒❒ Valve Replacement r Endometrosis r Cancer r Cyst
I o AUTHORIZE, o DO NOT AUTHORIZE, Clearlyderm employees to release my medical information ❒❒ Prostatethrough
Removed
❒❒ Mastectomy: r Left r Right ❒❒ Heart Transplant
telephone communication to myself or the identified people listed on my HIPAA form . ❒❒ Spleen Removed
❒❒ Lumpectomy: r Left r Right ❒❒ Joint Replacement
❒ Breast Implantso DO NOT AUTHORIZE, Clearydermr Knee r Hip r Right r Left ❒❒ Hysterectomy Due To:
I❒o AUTHORIZE, to leave medical information on my voice message on this
❒ ❒ Kidney Removed r Fibroids r Cervical Cancer r Uterine Cancer
designated telephone
❒❒ Gallbladder number: _______________________________________________
Removed
❒❒ Kidney Transplant ❒❒ Tuballigation
❒ Other
I❒o __________________________________________________________________________________
AUTHORIZE, o DO NOT AUTHORIZE, Clearyderm to send medical information to my phone via text message
on
❒❒ this
✔ Nonedesignated telephone number: __________________________________________________

I o AUTHORIZE, o DO NOT AUTHORIZE, Clearyderm to send medical information to my email at the designated
email address: _________________________________________________________________

S KIN
You DIS
give E AS E HI SLLC
ClearlyDerm T ORY:
and (PLEASE
it’s healthcare
CHECKproviders, authorization to perform medical treatment, therapy and
ALL THAT APPLY)
medication that may be indicated. Including but not limited to: biopsies, cryotherapy, ED&C, Laser Treatments Etc.
❒❒ Acne ❒❒ Dry Skin ❒❒ Poison Ivy
❒❒_________________________________
X Actinic Keratoses ❒❒ Eczema ❒X
X ______________________________________ ❒ Precancerous
____________ Moles
❒❒Print
Asthma
Patient Name ❒❒ Flaking or Itchy Scalp
Signature ❒❒ Psoriasis
Date
❒❒ Basal Cell Skin Cancer ❒❒ Hay Fever/Allergies ❒❒ Squamous Cell Skin
A PARENT ORYear
Location GUARDIAN MUST ACCOMPANY A MINOR TO THE INITIAL
❒❒ Melanoma VISIT
Location Year
MINOR
❒❒ Blistering Sunburns CONSENT: THIS SHOULD BE SIGNED
Location Year IF THE MINOR WILL
NOT BE WITH A PARENT, EXCEPT FOR THE INITIAL VISIT.
❒❒ Other ______________________________________________________________________________________
❒❒ None
I give the doctors and staff at ClearlyDerm permission to treat __________________________ in my absence.
Do you wear Sunscreen? ✔ o Yes o No
If yes, what SPF? ____________________
50
X _____________________________ X _________________________________ X ___________
Do you tan in a tanning salon? o Yes o No
Print Patient Name Signature Date
Do you have a family history of skin cancer? o Yes o No; if Yes, Type: o Melanoma o Basal / Squamous Cell o Unsure
If Melanoma, which relative(s)? ________________________________________________

Get Serious About Your Skin ®

 Get Serious About Your Skin ®

FINANCIAL
C A UTIO N S : (PLEASE POLICY:
CHECK ALL THAT APPLY)

•Do Payment ✔
you have aispacemaker?. . . . . . . . . . . . . . . . . . . . . . . . . .
due at the time of service, including co-payments and deductibles.
o Yes o No
•Do All
youcharges
have a defibrillator?. . . . . . . . . . . . . . . . . . . . . . . . . .
will become the patient’s financial responsibility o Yes oif No
your insurance carrier has not paid within 60 days.
Have you had an artificial joint replacement?. . . . . . . . . . . . o Yes o No
• All cosmetic procedures are paid at the time of service. We do not bill these procedures to insurance companies.
If yes, when and what body locations? ____________________________________________________
•Do Iyou
understand that if heart
have an artificial bloodvalve?. . . . . . . . . . . . . . . . . .
work or biopsies are done o that
Yes I many
o No receive a separate inovice from the laboratory or
the pathology doctor who review and interprets
Do you require antibiotics prior to a surgical procedure?. . . o Yes o No my biopsy specimens at a later date.
I will be responsible for paying all such invoices directly to the
Allergy to adhesives?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o Yes o No laboratory or physician.
•Allergy
I have to read
topical and
antibiotic
fullyointments?. . . . . . . . . . . . . . . . .
understand ClearlyDerm o Yes LLC’s
o Nofinancial policy.
Are you taking blood thinners or aspirin?. . . . . . . . . . . . . . . o Yes o No
Are you**THIS
pregnantSHOULD
or currently trying
BE SIGNED to get pregnant?. . . . .
BY THE o Yes o No
PERSON RESPONSIBLE FOR PAYMENT.**
Are you allergic to lidocaine?. . . . . . . . . . . . . . . . . . . . . . . . . o Yes o No
Signature:
Do you get rapid ______________________________________________
heartbeat with epinephrine?. . . . . . . . . . . o Yes o No
Printed Name: infections
Do you get yeast with antibiotics?. . . . . . . . . . . . o Yes
___________________________ Date: No
o ___________
Do you get GI upset with antibiotics?. . . . . . . . . . . . . . . . . . o Yes o No
Relationship: ____________________________________________

AUTHORIZATION TO DISCUSS/RELEASE MEDICAL INFORMATION & CONSENT FOR TREATMENT

M EDICAT I O N S : (PLEASE ENTER ALL CURRENT MEDICATIONS, INCLUDING VITAMINS AND OVER-THE-COUNTER)
ATORVASTATIN 10mg
(Optional) I authorize __________________________________, who is my ______________________________
to have access to/discuss my medical records.

I o AUTHORIZE, o DO NOT AUTHORIZE, Clearlyderm employees to release my medical information through

telephone communication to myself or the identified people listed on my HIPAA form .

I o AUTHORIZE, o DO NOT AUTHORIZE, Clearyderm to leave medical information on my voice message on this
designated telephone number: _______________________________________________

I o AUTHORIZE, o DO NOT AUTHORIZE, Clearyderm to send medical information to my phone via text message
on this designated telephone number: __________________________________________________
ALLERGI E S : (PLEASE ENTER ALL ALLERGIES TO MEDICATIONS)
I o AUTHORIZE, o DO NOT AUTHORIZE, Clearyderm to send medical information to my email at the designated
email address: _________________________________________________________________

You give ClearlyDerm LLC and it’s healthcare providers, authorization to perform medical treatment, therapy and
medication that may be indicated. Including but not limited to: biopsies, cryotherapy, ED&C, Laser Treatments Etc.

X _________________________________ X ______________________________________ X ____________

Print Patient
S OCIAL HI S TName Signature
O RY: (PLEASE CHECK ALL THAT APPLY) Date

A PARENT
❒❒ Currently Smokes OR GUARDIAN o Has MUST
smoked ACCOMPANY
in the past Ao MINOR TO THE INITIAL VISIT
Never Smoked
MINOR CONSENT: THIS SHOULD BE SIGNED IF THE
❒❒ Other ______________________________________________________________________________
MINOR WILL
❒❒ None
NOT BE WITH A PARENT, EXCEPT FOR THE INITIAL VISIT.
✔
I give the doctors and staff at ClearlyDerm permission to treat __________________________ in my absence.

XS IGNAT
_____________________________
URE: X _________________________________ X ___________
Print Patient Name Signature Date
Completed by: o Patient o Patient’s Parent o Guardian o Medical Assistant
Print Name (if not patient):
X X X
Print Patient Name Signature Date

Get Serious About Your Skin ®

 Get Serious About Your Skin ®

FINANCIAL POLICY:
HIPAA PRIVACY PATIENT CONSENT FORM:
• Payment is due at the time of service, including co-payments and deductibles.
• All charges will become the patient’s financial responsibility if your insurance carrier has not paid within 60 days.
Our Notice of Privacy Practices provides information about how we may use and disclose protected health
• All cosmetic procedures are paid at the time of service. We do not bill these procedures to insurance companies.
information about you. The Notice contains a Patient Rights section describing your rights under the law. You
• I have
understand that ifto
the right blood work our
review or biopsies
Noticeare done that
before I many
signing receive
this a separate
consent. inovice from
The terms theNotice
of our laboratory
may or change. If we
the pathology doctor who review and interprets my biopsy specimens at a later date.
change our Notice, you may obtain a revised copy by contacting our office.
I will be responsible for paying all such invoices directly to the laboratory or physician.
• I have
You read
have and fully to
the right understand ClearlyDerm
request that we restrict LLC’s financial health
how protected policy.information about you is used or
disclosed for treatment,
**THIS SHOULD paymentBY
BE SIGNED and health
THE care operations.
PERSON RESPONSIBLEYou have
FORthe right to revoke this consent
PAYMENT.**
this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we
Signature: ______________________________________________
have already made in reliance on your prior Consent. The Practice provides this form to comply with the
Printed Name: ___________________________
Health Insurance Portability and Accountability Date:
Act___________
of 1996 (HIPAA).
Relationship: ____________________________________________
The patient understands that:
AUTHORIZATION TO DISCUSS/RELEASE MEDICAL INFORMATION & CONSENT FOR TREATMENT
(Optional)• I authorize
Protected health information may be disclosed
__________________________________, whoor
is use for treatment, payment or health care
my ______________________________
operations;
to have access to/discuss my medical records.
• The o
I o AUTHORIZE, Practice
DO NOT has a Notice of
AUTHORIZE, Practicesemployees
Clearlyderm and that to the patient
release myhas the information
medical opportunity to review this
through
Notice;
telephone communication to myself or the identified people listed on my HIPAA form .

I o AUTHORIZE,
• The o DO NOT
Practice AUTHORIZE,
reserves Clearyderm
the right to leave
to change themedical
Noticeinformation
of PrivacyonPolicies;
my voice message on this
designated telephone number: _______________________________________________
• The o
I o AUTHORIZE, patient
DO NOThasAUTHORIZE,
the right toClearyderm
restrict the usesmedical
to send of theirinformation
information but
to my the via
phone Practice does not
text message
havetelephone
on this designated to agreenumber:
to those restrictions;
__________________________________________________

I o AUTHORIZE,
• The o DO NOT
patient AUTHORIZE,
may Clearyderm
revoke this consent to
in send medical
writing information
at any time andto my email atdisclosures
all future the designated
will then
email address: _________________________________________________________________
cease;
You give ClearlyDerm LLC and it’s healthcare providers, authorization to perform medical treatment, therapy and
• that
medication The Practice
may may Including
be indicated. condition
buttreatment upon
not limited to: the execution
biopsies, cryotherapy,ofED&C,
this Consent.
Laser Treatments Etc.

X _________________________________ X ______________________________________ X ____________

Print Patient Name Signature Date
X
Signature
A PARENT OR GUARDIAN MUST ACCOMPANY A MINOR TO THE INITIAL VISIT
MINOR CONSENT: THIS SHOULD BE SIGNED IF THE MINOR WILL
This Consent wasNOTsigned
BE WITHby Rick
A PARENT,
Pink EXCEPT FOR THE INITIAL VISIT.
Printed Name – Patient or Representative
I give the doctors and staff at ClearlyDerm permission to treat __________________________ in my absence.

X _____________________________ X _________________________________
Please bring this completed form to your first appointmentX ___________
Print Patient Name Signature Date

Get Serious About Your Skin ®