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.