Esthetician/Cosmetic Registration Form

Patient's Legal Name*

Date of Birth*

Age*

Mailing Address*

City

State

ZIP

Email Address

Home Number

Work Number

Cell Number

Preference



Parent or Guardian (if under 18)

Home Phone

Address (if different)


Emergency Contact:

Emergency Contact Relationship:

Emergency Contact Phone:


Person(s) allowed access to your cosmetic records and who may call on your behalf:

:

Four Seasons Dermatology Cosmetic Financial Policy

Thank you for choosing Four Seasons Dermatology. We look forward to establishing a lasting relationship as your dermatology provider. 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, or
    Discover).
  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.