Patient Portal

Registration Form

All new patients must provide the below registration information, either by submitting through our secure online form below, printing and filling out this paperwork, or by coming in 15-20 minutes early to fill out the paperwork at the office. While we prefer that you submit your information through the secure form below, if you would rather print out the form, fill it out, and bring it with you to your appointment, this will still speed up the registration process.

If you are interested in our cosmetic procedures and treatments, in addition to submitting the below form, please click here to open the cosmetics PDF file, print it, fill it out, and bring it in with you to discuss it with your provider.

Please do not print this page and bring it in with you to your appointment filled out. The formatting will not be correct for our records.

The * fields are required.


 
Referring Physician:
 
How did you hear about us:

PATIENT INFORMATION
*
Last Name:
*
First Name:
 
MI:
*
Date of birth:
(YYYY/MM/DD)
*
Social Security #:
(XXX-XX-XXXX)
*
Home Address:
*
City:
*
State:
*
Zip:
*
Sex:
Male Female
 
Spouse's name:
*
Home #:
(XXX-XXX-XXXX)
 
Work #:
(XXX-XXX-XXXX)
*
Marrital status:
Married Single Divorced Widowed Separated Partnership

EMPLOYMENT INFORMATION
*
Patient's employer or school name if student:
 
Occupation (job title):
*
Employment or student status:
Full-time Not employed Retired Part-time Self-employed Active military
 
Patient's employer's or school address:
 
City:
 
State:
 
Zip:

EMERGENCY INFORMATION
*
Next-of-kin (for emergency - other than spouse):
*
Relationship:
*
Next-of-kin address:
*
City:
*
State:
*
Zip:
*
Next-of-kin phone:

RESPONSIBLE PARTY INFORMATION
*
Last name:
*
First name:
 
MI:
*
Address:
*
City:
*
State:
*
Zip:
*
Social Security #:
(XXX-XX-XXXX)
 
Employer:
 
Occupation (job title):
*
Home #:
(XXX-XXX-XXXX)
 
Work #:
(XXX-XXX-XXXX)
 
Employer address:
 
Employer City:
 
Employer State:
 
Employer Zip:
*
Relationship to responsible party:
Self Spouse Son Daughter

INSURANCE INFORMATION
 
Primary Insurance:
 
Policy holder:
 
Date of birth:
(YYYY/MM/DD)
 
Group #:
 
Identification #:
 
Address:
 
City:
 
State:
 
Zip:
 
Phone #:
(XXX-XXX-XXXX)
 
Secondary insurance:
 
Policy holder:
 
Date of birth:
(YYYY/MM/DD)
 
Group #:
 
Identification #:
 
Address:
 
City:
 
State:
 
Zip:
 
Phone #:
(XXX-XXX-XXXX)

How can we contact you (check all that apply):
 
Yes No
By mail
 
Yes No
Home phone #: (XXX-XXX-XXXX)
 
Yes No
Cell phone #: (XXX-XXX-XXXX)
 
Yes No
Work phone #: (XXX-XXX-XXXX)
 
Yes No
Fax #: (XXX-XXX-XXXX)
 
Yes No
E-mail address:
 
Yes No
Okay to leave message with medical information (results, etc.)
Please list names of all persons okay to leave medical information with:




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© Uptown Dermatology & SkinSpa, P.A.
1221 W. Lake St #208
Minneapolis, MN 55408
(p) 612-455-3200
(f) 612-455-3299
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