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Patient Portal
Esthetician / Cosmetic Registration Form
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Patient's Legal Name
*
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Last
Gender
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Age
*
Date of Birth
*
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Email
*
Home Number
Work Number
Cell Number
Preference
Home
Work
Cell
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Home Phone
Address (if different)
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
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Ohio
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Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
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State
Zip Code
Emergency Contact
Emergency Contact Relationship
Emergency Contact Phone
Person(s) allowed access to your cosmetic records and who may call on your behalf
Access Expiration
Indefinite
Time Limit
How Long?
Four Seasons Dermatology Cosmetic Financial Policy
Thank you for choosing Four Seasons Dermatology. As part of this relationship, we wish to establish our expectations of your financial responsibility as outlined below. 1 - PAYMENT IS EXPECTED IN FULL. We accept cash, check, or credit card (Visa, MasterCard, Discover, and AMEX). 2 - COSMETIC SERVICES. Cosmetic procedures or consultations are not billable to insurers. 3 - RETURNED CHECKS will incur a $20.00 service charge. 4 - MISSED OR CANCELLED APPOINTMENTS. Esthetician customers that miss or cancel an appointment with less than 24-hour’s notice may be assessed a $50.00 charge.
Signature
*
Date
*
Please note that if you are more than 10 minutes late for your appointment, your appointment may need to be rescheduled.
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