LASER & DERM  SKIN CARE CENTER/  JOSEPH LEIKER M.D.

Please Complete the Following Information about the Patient (All is treated Privately
for  In Office use only):
Last Name _______________________First Name____________________ M.I._____________
Street Address__________________________________________________________________
City___________________________ State______________________ Zip__________________
Age_______ Birth Date________________ Social Security #.________________(check writing)
Driver’s License No._______________(check writing)    Expiration Date___________________
Phone (Home)________________________________ (Work)____________________________
Phone (Cell)_____________________________ E-mail_________________________________
Primary Care Physician___________________________________________________________
Referred By (if anyone)___________________________________________________________
Gender  F    M       Marital Status:    Single      Married      Divorced     Widowed
Employer Name ________________________________________________________________ Employer Address_______________________________________________________________
Spouse’s Name (S.O.)___________________________Phone Number_____________________

COMPLETE THE FOLLOWING IF THE PATIENT IS A MINOR:
Name of person completing form:
Last ________________________________First______________________________________
Relationship to Patient:     Father     Mother     Guardian      Other Specify:__________________
Address if different from patient’s__________________________________________________
Phone # Parent/Guardian:
Phone Home _______________Phone Work _________________Phone Cell_______________

EMERGENCY CONTACT—OTHER THAN HOUSEHOLD MEMBER:
Last Name___________________________ First Name_______________________ M.I.______
Relationship to Patient_______________________ Phone number________________________
Address _______________________________________________________________________
City_______________________________ State_________________ Zip___________________

Please Read and Sign:
Payment is due and payable at the time services are rendered. I understand I may receive separate bills for certain services provided outside this office, such as Radiology, Laboratory, or Pathology if these are necessary. I understand that laser and cosmetic services are not covered by insurance or medicare, and I am personally responsible for these services. Further I understand that laser and cosmetic services are pre-paid services paid prior to or at the time of services rendered, and that payments for these services are non-refundable. I certify that I understand and acknowledge the above conditions and that the information that I provided is true and correct under penalty of the law. Laser-Derm does not file or take any responsibility for insurance claims and in most circumstances insurance does not cover laser services, newer type technologies, or cosmetic services. I consent to be seen and treated as necessary by Laser-Derm Skin Care Center staff.

SIGNED: ____________________________________________DATE:______________________